Provider Demographics
NPI:1215104278
Name:JOHNSON, LAUREL LEIGH (DC, LAC, DIPL OM)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:LEIGH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DC, LAC, DIPL OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 SW MARLOW AVE
Mailing Address - Street 2:STE 309
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5104
Mailing Address - Country:US
Mailing Address - Phone:503-597-7780
Mailing Address - Fax:
Practice Address - Street 1:1675 SW MARLOW AVE
Practice Address - Street 2:STE 309
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5104
Practice Address - Country:US
Practice Address - Phone:503-597-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-09
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3904111N00000X
ORAC01256171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR155298Medicare PIN