Healthcare Provider Details

I. General information

NPI: 1316927288
Provider Name (Legal Business Name): BRUCE EDWARD JOHNSON CHIROPRACTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 11/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4627 W HOMEFIELD DR
SIOUX FALLS SD
57106-3511
US

IV. Provider business mailing address

4627 W HOMEFIELD DR
SIOUX FALLS SD
57106-3511
US

V. Phone/Fax

Practice location:
  • Phone: 605-336-2010
  • Fax: 605-336-0249
Mailing address:
  • Phone: 605-336-2010
  • Fax: 605-336-0249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number602
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: