Provider Demographics
NPI:1851570923
Name:MARK JOHNSON CHIROPRACTIC P.S.C.
Entity Type:Organization
Organization Name:MARK JOHNSON CHIROPRACTIC P.S.C.
Other - Org Name:PROWELLNESS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:859-431-4430
Mailing Address - Street 1:3955 ALEXANDRIA PIKE
Mailing Address - Street 2:
Mailing Address - City:COLD SPRING
Mailing Address - State:KY
Mailing Address - Zip Code:41076-2027
Mailing Address - Country:US
Mailing Address - Phone:859-431-4430
Mailing Address - Fax:859-431-9560
Practice Address - Street 1:3955 ALEXANDRIA PIKE
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:KY
Practice Address - Zip Code:41076-2027
Practice Address - Country:US
Practice Address - Phone:859-431-4430
Practice Address - Fax:859-431-9560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-25
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5076261Q00000X
363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00567001Medicare PIN