Provider Demographics
NPI:1508116146
Name:RUSSELL MAXWELL DC PS
Entity Type:Organization
Organization Name:RUSSELL MAXWELL DC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:STANLEY
Authorized Official - Last Name:MAXWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC, PS
Authorized Official - Phone:360-647-4438
Mailing Address - Street 1:805 W ORCHARD DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1759
Mailing Address - Country:US
Mailing Address - Phone:360-647-4438
Mailing Address - Fax:360-527-8144
Practice Address - Street 1:805 W ORCHARD DR
Practice Address - Street 2:SUITE 1
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1759
Practice Address - Country:US
Practice Address - Phone:360-647-4438
Practice Address - Fax:360-527-8144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002961261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029338Medicaid
WA2029338Medicaid
WA50168Medicare UPIN