Provider Demographics
NPI:1003905456
Name:RUSSELL, RENNY BEAU (DC)
Entity Type:Individual
Prefix:
First Name:RENNY
Middle Name:BEAU
Last Name:RUSSELL
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 1:8009 NE 105TH TER
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64157-9100
Mailing Address - Country:US
Mailing Address - Phone:816-824-9690
Mailing Address - Fax:
Practice Address - Street 1:6624 ROYAL ST
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64068-8711
Practice Address - Country:US
Practice Address - Phone:816-824-9690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3841111N00000X
MO2008015663111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor