Provider Demographics
NPI:1821105552
Name:JOHNSON, KIRBY VAN (DC)
Entity Type:Individual
Prefix:DR
First Name:KIRBY
Middle Name:VAN
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 1:5050 KANAN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-2516
Mailing Address - Country:US
Mailing Address - Phone:818-707-4200
Mailing Address - Fax:818-707-0880
Practice Address - Street 1:5050 KANAN RD
Practice Address - Street 2:SUITE B
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-2516
Practice Address - Country:US
Practice Address - Phone:818-707-4200
Practice Address - Fax:818-707-0880
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17252111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU29977Medicare UPIN
CADC17252Medicare ID - Type Unspecified