Provider Demographics
NPI:1134122765
Name:CLOUSE, RUSSELL LEROY (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LEROY
Last Name:CLOUSE
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 1:437 S GILBERT RD
Mailing Address - Street 2:STE 14
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-2866
Mailing Address - Country:US
Mailing Address - Phone:480-834-9000
Mailing Address - Fax:480-834-1880
Practice Address - Street 1:437 S GILBERT RD
Practice Address - Street 2:STE 14
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-2866
Practice Address - Country:US
Practice Address - Phone:480-834-9000
Practice Address - Fax:480-834-1880
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4560111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZDC4560Medicare ID - Type UnspecifiedPINAL COUNTY
AZZ81526Medicare ID - Type UnspecifiedMARICOPA COUNTY
AZAZ5450Medicare UPIN
AZAZ0943720Medicare UPIN