Provider Demographics
NPI:1568430627
Name:ELLIS, RUSSELL LANCE (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LANCE
Last Name:ELLIS
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 1:9029 RESEDA BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-3932
Mailing Address - Country:US
Mailing Address - Phone:818-701-0712
Mailing Address - Fax:818-701-9148
Practice Address - Street 1:9029 RESEDA BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-3932
Practice Address - Country:US
Practice Address - Phone:818-701-0712
Practice Address - Fax:818-701-9148
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14594111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician