Provider Demographics
NPI:1366516767
Name:KIMBERLEY M JOHNSON DC
Entity type:Organization
Organization Name:KIMBERLEY M JOHNSON DC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:651-257-3900
Mailing Address - Street 1:PO BOX 567
Mailing Address - Street 2:12814 LAKE BLVD
Mailing Address - City:LINDSTROM
Mailing Address - State:MN
Mailing Address - Zip Code:55045-0567
Mailing Address - Country:US
Mailing Address - Phone:651-257-3900
Mailing Address - Fax:651-257-3932
Practice Address - Street 1:12814 LAKE BOULEVARD
Practice Address - Street 2:
Practice Address - City:LINDSTROM
Practice Address - State:MN
Practice Address - Zip Code:55045
Practice Address - Country:US
Practice Address - Phone:651-257-3900
Practice Address - Fax:651-257-3932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3423111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
183022800OtherMA
02B15LA PIN 02B16J0OtherBCBS
350002146Medicare ID - Type Unspecified