MEDICARE: BRUCE EDWARD JOHNSON CHIROPRACTOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NS0005X	Sports Physician Chiropractor	602	SD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	20860	OTHER	SD	SIOUX VALLEY HEALTH PLAN
2	248015	OTHER		MIDLAND
3	4994546	OTHER	SD	WELLMARK
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316927288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE EDWARD JOHNSON CHIROPRACTOR

Provider Business Mailing Address
First Line	:	4627 W HOMEFIELD DR
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-3511
Country	:	US
Telephone Number	:	605-336-2010
Fax Number	:	605-336-0249

Provider Business Practice Location Address
First Line	:	4627 W HOMEFIELD DR
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57106-3511
Country	:	US
Telephone Number	:	605-336-2010
Fax Number	:	605-336-0249

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	11/06/2007

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