Provider Demographics
NPI:1942480306
Name:JOHNSON, GLENN A (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:A
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 1:500 9TH AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-4598
Mailing Address - Country:US
Mailing Address - Phone:303-772-4544
Mailing Address - Fax:
Practice Address - Street 1:500 9TH AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-4598
Practice Address - Country:US
Practice Address - Phone:303-772-4544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1289111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO13963Medicare UPIN