Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | DC15588 | CA |
NPI | 1699772012 |
---|---|
Provider Name | Dr. John M Johnsrud |
First Address | Citrus Heights, CA 95610-5603 |
Second Address | Citrus Heights, CA 95610-5603 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T05830 | (02) | CA |