MEDICARE: JOSHUA LEE JOHNSON D.C.

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	111N00000X	Chiropractor	27-2998137	IL
2	111N00000X	Chiropractor	038.011514	IL

General Provider Information

NPI Number	:	1619289261
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSHUA LEE JOHNSON D.C.

Provider Business Mailing Address
First Line	:	5278 E QUEENWOOD RD
Second Line	:
City	:	GROVELAND
State	:	IL
Zip	:	61535-9613
Country	:	US
Telephone Number	:	636-328-4939
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 SUSAN DR.
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761
Country	:	US
Telephone Number	:	636-328-4939
Fax Number	:

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

Provider Enumeration Date	:	07/12/2010
Last Update Date	:	08/11/2010

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