Provider Demographics
NPI:1417934241
Name:LARUSSO, SALVATORE D (DC)
Entity Type:Individual
Prefix:DR
First Name:SALVATORE
Middle Name:D
Last Name:LARUSSO
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 1:13860 WELLINGTON TRCE
Mailing Address - Street 2:SUITE # 13
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-8588
Mailing Address - Country:US
Mailing Address - Phone:561-793-4700
Mailing Address - Fax:561-793-5504
Practice Address - Street 1:13860 WELLINGTON TRCE
Practice Address - Street 2:SUITE # 13
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-8588
Practice Address - Country:US
Practice Address - Phone:561-793-4700
Practice Address - Fax:561-793-5504
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0003139111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL052677100Medicaid
FL88377AOtherBLUE CROSS BLUE SHIELD
FL350055830OtherRAILROAD MEDICARE
FL052677100Medicaid
FL88377AOtherBLUE CROSS BLUE SHIELD