Healthcare Provider Details

I. General information

NPI: 1639355654
Provider Name (Legal Business Name): CLELAND JOHNSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2008
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 PLAZA GARCIA B
TAOS NM
87571-6256
US

IV. Provider business mailing address

107 PLAZA GARCIA B
TAOS NM
87571-6256
US

V. Phone/Fax

Practice location:
  • Phone: 575-758-8829
  • Fax:
Mailing address:
  • Phone: 575-758-8829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1591
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6874
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: