MEDICARE: KRISTEN MARIE 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	038-008775	IL

General Provider Information

NPI Number	:	1992826119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN MARIE JOHANSEN D.C.

Provider Business Mailing Address
First Line	:	6852 W 111TH ST
Second Line	:
City	:	WORTH
State	:	IL
Zip	:	60482-1823
Country	:	US
Telephone Number	:	708-448-3818
Fax Number	:	708-448-3804

Provider Business Practice Location Address
First Line	:	6852 W 111TH ST
Second Line	:
City	:	WORTH
State	:	IL
Zip	:	60482-1823
Country	:	US
Telephone Number	:	708-448-3818
Fax Number	:	708-448-3804

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

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	10/15/2009

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