Provider Demographics
NPI:1093856486
Name:RUSSELL L. EVANS ENTERPRISES INC
Entity Type:Organization
Organization Name:RUSSELL L. EVANS ENTERPRISES INC
Other - Org Name:EVANS CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:501-268-1800
Mailing Address - Street 1:400 W RACE AVE
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-4133
Mailing Address - Country:US
Mailing Address - Phone:501-268-1800
Mailing Address - Fax:
Practice Address - Street 1:400 W RACE AVE
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-4133
Practice Address - Country:US
Practice Address - Phone:501-268-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1508111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C813Medicare UPIN