Provider Demographics
NPI:1568714376
Name:MARK V RUSSO, DC, LLC
Entity Type:Organization
Organization Name:MARK V RUSSO, DC, LLC
Other - Org Name:RUSSO CHIROPRACTIC AND REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-344-0129
Mailing Address - Street 1:157 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-1439
Mailing Address - Country:US
Mailing Address - Phone:973-344-0129
Mailing Address - Fax:973-344-0243
Practice Address - Street 1:157 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-1439
Practice Address - Country:US
Practice Address - Phone:973-344-0129
Practice Address - Fax:973-344-0243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-04
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MCOO235500111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT45295Medicare UPIN