Provider Demographics
NPI:1720356744
Name:KEVIN S. JOHNSON, D.C., PC
Entity Type:Organization
Organization Name:KEVIN S. JOHNSON, D.C., PC
Other - Org Name:GREAT BASIN CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-573-7733
Mailing Address - Street 1:229 N EGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BURNS
Mailing Address - State:OR
Mailing Address - Zip Code:97720-1741
Mailing Address - Country:US
Mailing Address - Phone:541-573-7733
Mailing Address - Fax:541-573-7732
Practice Address - Street 1:229 N EGAN AVE
Practice Address - Street 2:
Practice Address - City:BURNS
Practice Address - State:OR
Practice Address - Zip Code:97720-1741
Practice Address - Country:US
Practice Address - Phone:541-573-7733
Practice Address - Fax:541-573-7732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2166111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR107808Medicare PIN