Provider Demographics
NPI:1790835403
Name:JOHNSON CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:JOHNSON CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:281-342-2603
Mailing Address - Street 1:1417 CARLISLE ST
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-3320
Mailing Address - Country:US
Mailing Address - Phone:281-342-2603
Mailing Address - Fax:281-342-9603
Practice Address - Street 1:1417 CARLISLE ST
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-3320
Practice Address - Country:US
Practice Address - Phone:281-342-2603
Practice Address - Fax:281-342-9603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2838111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX601102Medicare ID - Type Unspecified