Provider Demographics
NPI:1568507697
Name:JOHNIGK, ROGER MICHAEL (DC)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:MICHAEL
Last Name:JOHNIGK
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:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:WA
Mailing Address - Zip Code:98591-0339
Mailing Address - Country:US
Mailing Address - Phone:360-864-6666
Mailing Address - Fax:360-864-2077
Practice Address - Street 1:205 COWLITZ STREET
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:WA
Practice Address - Zip Code:98591
Practice Address - Country:US
Practice Address - Phone:360-864-6666
Practice Address - Fax:360-864-2077
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA14972OtherLABOR & INDUSTRIES
WA2001006Medicaid
WAG000917062Medicare ID - Type Unspecified