Provider Demographics
NPI:1033156369
Name:WILLEMIN, RUSSELL W (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:W
Last Name:WILLEMIN
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 1:912 E GRAND RIVER AVE
Mailing Address - Street 2:PO BOX 368
Mailing Address - City:PORTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48875-1664
Mailing Address - Country:US
Mailing Address - Phone:517-647-7585
Mailing Address - Fax:517-647-2666
Practice Address - Street 1:912 E GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:MI
Practice Address - Zip Code:48875-1664
Practice Address - Country:US
Practice Address - Phone:517-647-7585
Practice Address - Fax:517-647-2666
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301004607111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT32898Medicare UPIN
MI0C45014Medicare ID - Type Unspecified