MEDICARE: DR. CHARLES J JOHNSON DC

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	2002018322	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	136189	OTHER		GHP
2	184750	OTHER		BCBS OF MO

General Provider Information

NPI Number	:	1780651984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES J JOHNSON DC

Provider Business Mailing Address
First Line	:	1006 MAIN STREET
Second Line	:	SUITE B
City	:	IMPERIAL
State	:	MO
Zip	:	63052
Country	:	US
Telephone Number	:	636-461-1800
Fax Number	:	636-461-0581

Provider Business Practice Location Address
First Line	:	1006 MAIN STREET
Second Line	:	SUITE B
City	:	IMPERIAL
State	:	MO
Zip	:	63052
Country	:	US
Telephone Number	:	636-461-1800
Fax Number	:	636-461-0581

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

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. CHARLES J JOHNSON DC” Practice Location

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