Provider Demographics
NPI:1467622480
Name:RUSSELL CHIROPRACTIC LTD
Entity Type:Organization
Organization Name:RUSSELL CHIROPRACTIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:216-221-1788
Mailing Address - Street 1:18624 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3202
Mailing Address - Country:US
Mailing Address - Phone:216-221-1788
Mailing Address - Fax:216-221-2820
Practice Address - Street 1:18624 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3202
Practice Address - Country:US
Practice Address - Phone:216-221-1788
Practice Address - Fax:216-221-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3307111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2321553Medicaid
OH232365OtherANTHEM
OH299807273002OtherMEDICAL MUTUAL
OH232365OtherANTHEM