Healthcare Provider Details

I. General information

NPI: 1770023137
Provider Name (Legal Business Name): CHAD JOHNSON MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W STOUT ST
RICE LAKE WI
54868
US

IV. Provider business mailing address

1700 W STOUT ST
RICE LAKE WI
54868-5000
US

V. Phone/Fax

Practice location:
  • Phone: 715-236-6367
  • Fax:
Mailing address:
  • Phone: 715-236-6367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: