Healthcare Provider Details

I. General information

NPI: 1043393838
Provider Name (Legal Business Name): DERREK JOHNSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5482 COUNTY ROAD 18
NISSWA MN
56468
US

IV. Provider business mailing address

PO BOX 379
NISSWA MN
56468-0379
US

V. Phone/Fax

Practice location:
  • Phone: 218-963-3311
  • Fax: 218-963-3313
Mailing address:
  • Phone: 218-963-3311
  • Fax: 218-963-3313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC4116
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: