=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154553006
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHNSON CHIROPRACTIC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2009
-----------------------------------------------------
Last Update Date | 08/11/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 E MAIN ST
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67301-3713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-331-0601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 E MAIN ST
-----------------------------------------------------
City | INDEPENDENCE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67301-3713
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-331-0601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE
-----------------------------------------------------
Name | DR. GARY M JOHNSON
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 620-331-0601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | C-3510
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------