Provider Demographics
NPI:1477554665
Name:MORELAND, RUSSELL (DC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:MORELAND
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 1:631 N LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1347
Mailing Address - Country:US
Mailing Address - Phone:815-464-8450
Mailing Address - Fax:815-464-8451
Practice Address - Street 1:631 N LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1347
Practice Address - Country:US
Practice Address - Phone:815-464-8450
Practice Address - Fax:815-464-8451
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL596740/596740Medicare ID - Type UnspecifiedGROUP#/PROV#
ILT37229Medicare UPIN