Provider Demographics
NPI:1053756445
Name:JOHANSSON, TAVIS M (DC)
Entity type:Individual
Prefix:
First Name:TAVIS
Middle Name:M
Last Name:JOHANSSON
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 1:6018 SE STARK ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1990
Mailing Address - Country:US
Mailing Address - Phone:503-808-9145
Mailing Address - Fax:503-473-8085
Practice Address - Street 1:6018 SE STARK ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1990
Practice Address - Country:US
Practice Address - Phone:503-808-9145
Practice Address - Fax:503-473-8085
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5139111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor