Provider Demographics
NPI:1558428821
Name:TAGG, RUSSELL S (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:S
Last Name:TAGG
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 1:1045 JADWIN AVE STE B1
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3400
Mailing Address - Country:US
Mailing Address - Phone:509-943-0695
Mailing Address - Fax:
Practice Address - Street 1:1045 JADWIN AVE STE B1
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3400
Practice Address - Country:US
Practice Address - Phone:509-943-0695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002726111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA36086OtherDEPT OF LABOR AND INDUSTR
WAGAB35157Medicare ID - Type Unspecified
WAU34023Medicare UPIN