Healthcare Provider Details

I. General information

NPI: 1134393804
Provider Name (Legal Business Name): PREMIER CHIROPRACTIC AND WELLNESS CENTER PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2008
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 BEACHWOOD CT SUITE 203
JACKSONVILLE FL
32224-5706
US

IV. Provider business mailing address

3500 BEACHWOOD CT SUITE 203
JACKSONVILLE FL
32224-5706
US

V. Phone/Fax

Practice location:
  • Phone: 904-996-6922
  • Fax: 904-996-6923
Mailing address:
  • Phone: 904-996-6922
  • Fax: 904-996-6923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH8655
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberCH8655
License Number StateFL

VIII. Authorized Official

Name: DR. KIM MICHELLE JOHNSTON
Title or Position: CHIROPRACTIC PHYSICIAN
Credential: D.C.
Phone: 904-996-6922