Provider Demographics
NPI:1124194519
Name:FOWLER, RUSSELL (DC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:FOWLER
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:PO BOX 10182
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-0182
Mailing Address - Country:US
Mailing Address - Phone:602-373-5115
Mailing Address - Fax:417-881-4282
Practice Address - Street 1:1675 E SEMINOLE ST
Practice Address - Street 2:SUITE H2
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2490
Practice Address - Country:US
Practice Address - Phone:417-881-2295
Practice Address - Fax:417-881-4282
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7087111N00000X
MO20144016190111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA5075001Medicare PIN
AZV03943Medicare UPIN