Healthcare Provider Details

I. General information

NPI: 1366771370
Provider Name (Legal Business Name): LARRY D JOHNSON DC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2009
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1510 HANCOCK BRIDGE PKWY #6
CAPE CORAL FL
33990-1715
US

IV. Provider business mailing address

1510 HANCOCK BRIDGE PKWY #6
CAPE CORAL FL
33990-1715
US

V. Phone/Fax

Practice location:
  • Phone: 239-574-5559
  • Fax: 239-574-9454
Mailing address:
  • Phone: 239-574-5559
  • Fax: 239-574-9454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LARRY DEAN JOHNSON
Title or Position: MGR
Credential: DC
Phone: 239-574-5559