Healthcare Provider Details

I. General information

NPI: 1629304712
Provider Name (Legal Business Name): DAVID C JOHNSON LMT, NCTMB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 10/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 N MAIN ST
TROY IL
62294-1129
US

IV. Provider business mailing address

102 N MAIN ST
TROY IL
62294-1129
US

V. Phone/Fax

Practice location:
  • Phone: 618-667-9766
  • Fax: 618-667-9770
Mailing address:
  • Phone: 618-667-9766
  • Fax: 618-667-9770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number227010448
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: