Healthcare Provider Details

I. General information

NPI: 1528782059
Provider Name (Legal Business Name): CHRISTOPHER JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20175 COUNTY ROAD 50
CORCORAN MN
55340-9345
US

IV. Provider business mailing address

20175 COUNTY ROAD 50
CORCORAN MN
55340-9345
US

V. Phone/Fax

Practice location:
  • Phone: 608-335-7203
  • Fax:
Mailing address:
  • Phone: 608-335-7203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: