Provider Demographics
NPI:1780651984
Name:JOHNSON, CHARLES J (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:JOHNSON
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 1:1006 MAIN STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052
Mailing Address - Country:US
Mailing Address - Phone:636-461-1800
Mailing Address - Fax:636-461-0581
Practice Address - Street 1:1006 MAIN STREET
Practice Address - Street 2:SUITE B
Practice Address - City:IMPERIAL
Practice Address - State:MO
Practice Address - Zip Code:63052
Practice Address - Country:US
Practice Address - Phone:636-461-1800
Practice Address - Fax:636-461-0581
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002018322111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
136189OtherGHP
184750OtherBCBS OF MO
184750OtherBCBS OF MO
U94079Medicare UPIN