Provider Demographics
NPI:1093037830
Name:RUSS FASOLINO INC.
Entity Type:Organization
Organization Name:RUSS FASOLINO INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:
Authorized Official - Last Name:FASOLINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC, LAC
Authorized Official - Phone:970-870-8888
Mailing Address - Street 1:PO BOX 772583
Mailing Address - Street 2:320 OAK ST.
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80477-2583
Mailing Address - Country:US
Mailing Address - Phone:970-870-8888
Mailing Address - Fax:970-870-3076
Practice Address - Street 1:320 OAK ST.
Practice Address - Street 2:
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487
Practice Address - Country:US
Practice Address - Phone:970-870-8888
Practice Address - Fax:970-870-3976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2010-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2475111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC48563Medicare PIN