MEDICARE: DR. SPENCER DANIEL JOHANSEN D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	0104001208	VA

General Provider Information

NPI Number	:	1164495784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SPENCER DANIEL JOHANSEN D.C.

Provider Business Mailing Address
First Line	:	2416 VIRGINIA BEACH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-3993
Country	:	US
Telephone Number	:	757-422-2000
Fax Number	:	757-422-1151

Provider Business Practice Location Address
First Line	:	2416 VIRGINIA BEACH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-3993
Country	:	US
Telephone Number	:	757-422-2000
Fax Number	:	757-422-1151

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2006
Last Update Date	:	09/10/2013

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