Healthcare Provider Details

I. General information

NPI: 1043302409
Provider Name (Legal Business Name): RONALD R JOHANSEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12762 SE STARK ST PLAZA 125 BLDG D
PORTLAND OR
97233-1539
US

IV. Provider business mailing address

12762 SE STARK ST PLAZA 125 BLDG D
PORTLAND OR
97233-1539
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-7746
  • Fax: 503-255-0818
Mailing address:
  • Phone: 503-255-7746
  • Fax: 503-255-0818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number27-1737
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: