Healthcare Provider Details

I. General information

NPI: 1285931923
Provider Name (Legal Business Name): GARY DAVID JOHNSON D.C., DCBCN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 09/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 W MORGAN ST
DULUTH MN
55811-4432
US

IV. Provider business mailing address

413 W. MORGAN STREET
DULUTH MN
55811
US

V. Phone/Fax

Practice location:
  • Phone: 218-343-3412
  • Fax: 218-724-7826
Mailing address:
  • Phone: 218-343-3412
  • Fax: 218-724-7826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number1651
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: