Provider Demographics
NPI:1659436350
Name:JOHNSON CHIROPRACTIC OFFICE, S.C.
Entity Type:Organization
Organization Name:JOHNSON CHIROPRACTIC OFFICE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:920-324-5641
Mailing Address - Street 1:716 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1230
Mailing Address - Country:US
Mailing Address - Phone:920-324-5641
Mailing Address - Fax:920-324-5655
Practice Address - Street 1:716 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1230
Practice Address - Country:US
Practice Address - Phone:920-324-5641
Practice Address - Fax:920-324-5655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1419-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT62342Medicare UPIN