1366516767 NPI number — KIMBERLEY M JOHNSON DC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366516767 NPI number — KIMBERLEY M JOHNSON DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBERLEY M JOHNSON DC
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:
1366516767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 567
Provider Second Line Business Mailing Address:
12814 LAKE BLVD
Provider Business Mailing Address City Name:
LINDSTROM
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55045-0567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-257-3900
Provider Business Mailing Address Fax Number:
651-257-3932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12814 LAKE BOULEVARD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINDSTROM
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55045
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-257-3900
Provider Business Practice Location Address Fax Number:
651-257-3932
Provider Enumeration Date:
11/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
KIMBERLEY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIROPRACTOR OWNER
Authorized Official Telephone Number:
651-257-3900

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3423 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 183022800 . This is a "MA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02B15LA PIN 02B16J0 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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