Healthcare Provider Details

I. General information

NPI: 1588670863
Provider Name (Legal Business Name): KEVIN DOUGLAS JOHNSTON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 LEWIS PARK DR
MT ZION IL
62549-1202
US

IV. Provider business mailing address

160 LEWIS PARK DR
MT ZION IL
62549-1202
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-5954
  • Fax: 217-864-6362
Mailing address:
  • Phone: 217-864-5954
  • Fax: 217-864-6362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038008355
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: