1164458469 NPI number — JOHNSTON CHIROPRACTIC CLINIC, INC.

Table of content: (NPI 1164458469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164458469 NPI number — JOHNSTON CHIROPRACTIC CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNSTON CHIROPRACTIC CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164458469
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1150 GROVE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93401-2914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-541-2727
Provider Business Mailing Address Fax Number:
805-541-2729

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1150 GROVE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-2914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-541-2727
Provider Business Practice Location Address Fax Number:
805-541-2729
Provider Enumeration Date:
06/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JOHNSTON
Authorized Official First Name:
R. MARC
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
805-541-2727

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  11453 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DC11453 . This is a "OTHER INS. INDIVIDUAL #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: WDC11453A . This is a "OTHER INS. INDIVIDUAL #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ86105Z . This is a "BLUE CROSS/SHIELD GROUP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".