Healthcare Provider Details

I. General information

NPI: 1275974545
Provider Name (Legal Business Name): JOHNSON CHIROPRACTIC, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 SUSAN DR SUITE 2
NORMAL IL
61761-6246
US

IV. Provider business mailing address

310 SUSAN DR SUITE 2
NORMAL IL
61761-6246
US

V. Phone/Fax

Practice location:
  • Phone: 309-808-1123
  • Fax: 309-808-1516
Mailing address:
  • Phone: 309-808-1123
  • Fax: 309-808-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number038.011514
License Number StateIL

VIII. Authorized Official

Name: DR. JOSHUA L JOHNSON
Title or Position: OWNER/CHIROPRACTOR
Credential: D.C.
Phone: 309-808-1123