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General NPI Number Information
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NPI Number | 1255680831
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Entity Type | Individual
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Provider Name | MARK RONALD JOHANSEN D.C.
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Gender | Male
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Dates
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Enumeration Date | 08/29/2012
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Last Update Date | 09/04/2012
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Provider Practice Location Address
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Address Line | 12762 SE STARK ST PLAZA 125 BLDG. D
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City | PORTLAND
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State | OR
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Zip | 97233-1539
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Country | US
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Telephone | 503-255-7746
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Fax |
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Provider Business Mailing Address
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Address Line | 14661 SE 172ND AVE
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City | CLACKAMAS
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State | OR
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Zip | 97015-7771
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Country | US
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Telephone | 503-998-5314
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5072
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License Number State | OR
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