Provider Demographics
NPI:1871058487
Name:JOHNSON, TRAVIS (DC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
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 1:8147 GLOBE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3379
Mailing Address - Country:US
Mailing Address - Phone:651-731-0505
Mailing Address - Fax:651-731-0500
Practice Address - Street 1:400 2ND ST S STE 165
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-1593
Practice Address - Country:US
Practice Address - Phone:715-808-0723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-07
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6597111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6597OtherBLUE CROSS BLUE SHIELD, HEALTH PARTNERS, CIGNA, CHIROCARE