| Doctor Name: | TAVIS M JOHANSSON |
| NPI Number: | 1053756445 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.C. |
| License Number: | 5139 |
| Business Practice Address: | 6018 Se Stark St Suite 103 Portland, OR - 972151990 |
| Business Phone Number: | 5038089145 |
| Business Fax Number: | 5034738085 |
| Mailing Address: | 6018 Se Stark St, Suite 103 PORTLAND |
| State: | OR |
| Postal Code: | 972151990 |
| Phone Number: | 5038089145 |
| Fax Number: | 5034738085 |
| NPI Enumeration Date: | 04/30/2013 |
| NPI Last Update Date: | 04/30/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | 5139 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |