Provider Demographics
NPI:1336657733
Name:RUSSELL, ADAM CORY
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:CORY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 LEONARD ST NW STE 2
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4267
Mailing Address - Country:US
Mailing Address - Phone:616-458-9520
Mailing Address - Fax:616-458-9532
Practice Address - Street 1:260 LEONARD ST NW STE 2
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4267
Practice Address - Country:US
Practice Address - Phone:616-458-9520
Practice Address - Fax:616-458-9532
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator