Provider Demographics
NPI:1063623189
Name:JOHNSON CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:JOHNSON CHIROPRACTIC CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-834-2118
Mailing Address - Street 1:PO BOX 486
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:FL
Mailing Address - Zip Code:32538-0486
Mailing Address - Country:US
Mailing Address - Phone:850-834-2118
Mailing Address - Fax:850-834-3110
Practice Address - Street 1:22395 US HIGHWAY 331 NORTH
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:FL
Practice Address - Zip Code:32538-0486
Practice Address - Country:US
Practice Address - Phone:850-834-2118
Practice Address - Fax:850-834-3110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL45729OtherBCBS OF FL