Provider Demographics
NPI:1093730400
Name:ALLEN, RUSSELL C (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:C
Last Name:ALLEN
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 1:4771 N SUMMIT WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5017
Mailing Address - Country:US
Mailing Address - Phone:208-994-4747
Mailing Address - Fax:
Practice Address - Street 1:4771 N SUMMIT WAY STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5017
Practice Address - Country:US
Practice Address - Phone:208-994-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA1018111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU97435Medicare UPIN
ID1675373Medicare ID - Type Unspecified