MEDICARE: DR. JAY W 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	2718	MN

General Provider Information

NPI Number	:	1679760219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAY W JOHNSON D.C.

Provider Business Mailing Address
First Line	:	1208 WASHINGTON AVE
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3906
Country	:	US
Telephone Number	:	218-847-2809
Fax Number	:

Provider Business Practice Location Address
First Line	:	1208 WASHINGTON AVE
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3906
Country	:	US
Telephone Number	:	218-847-2809
Fax Number	:

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

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	09/14/2009

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