Healthcare Provider Details

I. General information

NPI: 1154811412
Provider Name (Legal Business Name): JOHNSON CHIROPRACTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2018
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 E CITIZENS DR STE 6
FAYETTEVILLE AR
72703-4797
US

IV. Provider business mailing address

2630 E CITIZENS DR STE 6
FAYETTEVILLE AR
72703-4797
US

V. Phone/Fax

Practice location:
  • Phone: 479-709-2014
  • Fax:
Mailing address:
  • Phone: 479-709-2014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number16072
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. BROCK JOHNSON
Title or Position: OWNER, CEO
Credential: D.C.
Phone: 479-935-6021