1124180450 NPI number — DR. RANDY ROBERT JOHNSON DC

Table of content: DR. RANDY ROBERT JOHNSON DC (NPI 1124180450)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124180450 NPI number — DR. RANDY ROBERT JOHNSON DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
RANDY
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

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:
1124180450
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1706 EAST TENTH STREET
Provider Second Line Business Mailing Address:
GAUER CHIROPRACTIC CLINIC
Provider Business Mailing Address City Name:
GLENCOE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-864-3196
Provider Business Mailing Address Fax Number:
320-864-3197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1706 EAST TENTH STREET
Provider Second Line Business Practice Location Address:
GAUER CHIROPRACTIC CLINIC
Provider Business Practice Location Address City Name:
GLENCOE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-864-3196
Provider Business Practice Location Address Fax Number:
320-864-3197
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4635 , 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: 30701128 . This is a "PRIME WEST" identifier . This identifiers is of the category "OTHER".
  • Identifier: 869035 . This is a "AMERICAS PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 649104 . This is a "CHIROPRACTIC CARE OF MINN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 370K6J0 . This is a "BCBS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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