Provider Demographics
NPI:1366771370
Name:LARRY D JOHNSON DC LLC
Entity type:Organization
Organization Name:LARRY D JOHNSON DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-574-5559
Mailing Address - Street 1:1510 HANCOCK BRIDGE PKWY #6
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-1715
Mailing Address - Country:US
Mailing Address - Phone:239-574-5559
Mailing Address - Fax:239-574-9454
Practice Address - Street 1:1510 HANCOCK BRIDGE PKWY #6
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-1715
Practice Address - Country:US
Practice Address - Phone:239-574-5559
Practice Address - Fax:239-574-9454
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LARRY D JOHNSON DC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-12-22
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381717200Medicaid
FLCW126AMedicare PIN
70987Medicare PIN
FL70987YMedicare PIN
T55086Medicare UPIN