Provider Demographics
NPI:1407981079
Name:RUSSELL, CHANTAL (DC, LAC)
Entity Type:Individual
Prefix:DR
First Name:CHANTAL
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10793 TIERRASANTA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-2629
Mailing Address - Country:US
Mailing Address - Phone:858-573-1505
Mailing Address - Fax:
Practice Address - Street 1:10793 TIERRASANTA BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-2629
Practice Address - Country:US
Practice Address - Phone:858-573-1505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29891111N00000X
CAAC11156171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC29891OtherCHIROPRACTOR
CAAC11156OtherLICENSED ACUPUNCTURIST