Provider Demographics
NPI:1518955947
Name:PRENTICE, RUSSELL JERIAH (DC)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JERIAH
Last Name:PRENTICE
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 1:9428 S ELWOOD AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2317
Mailing Address - Country:US
Mailing Address - Phone:918-296-0525
Mailing Address - Fax:918-296-0526
Practice Address - Street 1:9428 S ELWOOD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2317
Practice Address - Country:US
Practice Address - Phone:918-296-0525
Practice Address - Fax:918-296-0526
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:2006-12-29
Deactivation Code:
Reactivation Date:2007-01-04
Provider Licenses
StateLicense IDTaxonomies
OK3725111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104991280OtherGROUP NPI PRENTICE FAMILY
1104991280OtherGROUP NPI PRENTICE FAMILY