Provider Demographics
NPI:1033320593
Name:ERIC G. RUSSELL
Entity Type:Organization
Organization Name:ERIC G. RUSSELL
Other - Org Name:BEACON CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:903-886-3100
Mailing Address - Street 1:1205 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:TX
Mailing Address - Zip Code:75428-2613
Mailing Address - Country:US
Mailing Address - Phone:903-886-3100
Mailing Address - Fax:903-886-3177
Practice Address - Street 1:1205 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:TX
Practice Address - Zip Code:75428-2613
Practice Address - Country:US
Practice Address - Phone:903-886-3100
Practice Address - Fax:903-886-3177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2009-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9291111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1336183904OtherNPI
TX1033320593OtherNPI
TX609779Medicare PIN
TX1033320593OtherNPI