Provider Demographics
NPI:1366591935
Name:JOHNSON CHIROPRACTIC CENTER, P.S.C.
Entity type:Organization
Organization Name:JOHNSON CHIROPRACTIC CENTER, P.S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:HAFFORD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:270-842-4211
Mailing Address - Street 1:915 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-2362
Mailing Address - Country:US
Mailing Address - Phone:270-842-4211
Mailing Address - Fax:270-842-2604
Practice Address - Street 1:915 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-2362
Practice Address - Country:US
Practice Address - Phone:270-842-4211
Practice Address - Fax:270-842-2604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8590019900Medicaid
KY6034402Medicare ID - Type Unspecified
KY8590019900Medicaid