Provider Demographics
NPI:1689740482
Name:MANSOUR, JOHNNY (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:
Last Name:MANSOUR
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 EXCISE AVENUE
Mailing Address - Street 2:109
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761
Mailing Address - Country:US
Mailing Address - Phone:909-937-6767
Mailing Address - Fax:909-937-0353
Practice Address - Street 1:1801 EXCISE AVENUE
Practice Address - Street 2:SUITE 109
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761
Practice Address - Country:US
Practice Address - Phone:909-937-6767
Practice Address - Fax:909-937-0353
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25895111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVO5363OtherBLUE CROSS
CAVO5363OtherBLUE CROSS