Provider Demographics
NPI:1861605230
Name:JOHNSON, JUSTIN BRUCE (DC)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:BRUCE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE FOURCHE
Mailing Address - State:SD
Mailing Address - Zip Code:57717-2010
Mailing Address - Country:US
Mailing Address - Phone:605-642-3582
Mailing Address - Fax:605-642-3582
Practice Address - Street 1:4029 E. COLORADO BLVD
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783
Practice Address - Country:US
Practice Address - Phone:605-722-4795
Practice Address - Fax:605-722-4815
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1046111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor