Provider Demographics
NPI:1568151082
Name:RUSSELL, MICHAEL SHANE (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHANE
Last Name:RUSSELL
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 1:3517 PEGRAM CIR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2159
Mailing Address - Country:US
Mailing Address - Phone:504-583-0822
Mailing Address - Fax:
Practice Address - Street 1:403 N SIXTH STREET
Practice Address - Street 2:STE 8 AND STE 9
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291
Practice Address - Country:US
Practice Address - Phone:318-303-6142
Practice Address - Fax:318-855-8453
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty