Provider Demographics
NPI:1669593315
Name:JOHNSON CHIROPRACTIC CLINIC, P.C.
Entity type:Organization
Organization Name:JOHNSON CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-852-2885
Mailing Address - Street 1:109 S BURR BLVD
Mailing Address - Street 2:
Mailing Address - City:KEWANEE
Mailing Address - State:IL
Mailing Address - Zip Code:61443-2219
Mailing Address - Country:US
Mailing Address - Phone:309-852-2885
Mailing Address - Fax:309-854-6410
Practice Address - Street 1:109 S BURR BLVD
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-2219
Practice Address - Country:US
Practice Address - Phone:309-852-2885
Practice Address - Fax:309-854-6410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004465111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3715466OtherBLUE CROSS BLUE SHIELD
IL206050Medicare PIN
ILT78276Medicare UPIN