Provider Demographics
NPI:1528133238
Name:JOHNSON, KELLY D (DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:D
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 1:29939 EASTVALE CT
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4422
Mailing Address - Country:US
Mailing Address - Phone:818-991-3190
Mailing Address - Fax:
Practice Address - Street 1:30313 CANWOOD ST
Practice Address - Street 2:#33
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4326
Practice Address - Country:US
Practice Address - Phone:818-991-4900
Practice Address - Fax:818-991-4509
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14646111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWDC14646AMedicare PIN