MEDICARE: MR. KEVIN DOUGLAS JOHNSTON DC

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	038008355	IL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	350046226	OTHER		RR MEDICARE

General Provider Information

NPI Number	:	1588670863
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN DOUGLAS JOHNSTON DC

Provider Business Mailing Address
First Line	:	160 LEWIS PARK DR
Second Line	:
City	:	MT ZION
State	:	IL
Zip	:	62549-1202
Country	:	US
Telephone Number	:	217-864-5954
Fax Number	:	217-864-6362

Provider Business Practice Location Address
First Line	:	160 LEWIS PARK DR
Second Line	:
City	:	MT ZION
State	:	IL
Zip	:	62549-1202
Country	:	US
Telephone Number	:	217-864-5954
Fax Number	:	217-864-6362

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	04/28/2016

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