Provider Demographics
NPI:1316927288
Name:JOHNSON, BRUCE EDWARD (CHIROPRACTOR)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:EDWARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4627 W HOMEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57106-3511
Mailing Address - Country:US
Mailing Address - Phone:605-336-2010
Mailing Address - Fax:605-336-0249
Practice Address - Street 1:4627 W HOMEFIELD DR
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57106-3511
Practice Address - Country:US
Practice Address - Phone:605-336-2010
Practice Address - Fax:605-336-0249
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD602111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD20860OtherSIOUX VALLEY HEALTH PLAN
248015OtherMIDLAND
SD4994546OtherWELLMARK
SD7600882Medicaid
SD7600882Medicaid