Provider Demographics
NPI:1891856688
Name:JOHNSON, KURT A
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20671 LAKE FOREST DR STE B102
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-7746
Mailing Address - Country:US
Mailing Address - Phone:949-587-9990
Mailing Address - Fax:949-587-0485
Practice Address - Street 1:20671 LAKE FOREST DR STE B102
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-7746
Practice Address - Country:US
Practice Address - Phone:949-587-9990
Practice Address - Fax:949-587-0485
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC17212111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor