Provider Demographics
NPI:1023422193
Name:JOHANSEN, JOHN BROCK (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:BROCK
Last Name:JOHANSEN
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 1:34406 N 27TH DR STE 139
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-7733
Mailing Address - Country:US
Mailing Address - Phone:623-440-8491
Mailing Address - Fax:
Practice Address - Street 1:5425 E BELL RD STE 150
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6010
Practice Address - Country:US
Practice Address - Phone:602-493-9800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8360111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor