Provider Demographics
NPI:1104010537
Name:RUSSELL WELLNESS CLINIC
Entity Type:Organization
Organization Name:RUSSELL WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:OWEN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-333-3363
Mailing Address - Street 1:2523 SE WASHINGTON BLVD.
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-8336
Mailing Address - Country:US
Mailing Address - Phone:918-333-3363
Mailing Address - Fax:
Practice Address - Street 1:2523 SE WASHINGTON BLVD.
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-8336
Practice Address - Country:US
Practice Address - Phone:918-333-3363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3166111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDF3888OtherPALMETTO GROUP
OKDF3888OtherPALMETTO GROUP
OKU49806Medicare UPIN