Provider Demographics
NPI:1609019587
Name:RENNY RUSSELL DC PC
Entity Type:Organization
Organization Name:RENNY RUSSELL DC PC
Other - Org Name:DR. RENNY RUSSELL DC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENNY
Authorized Official - Middle Name:BEAU
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-824-9690
Mailing Address - Street 1:6624 ROYAL ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VALLEY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-8711
Mailing Address - Country:US
Mailing Address - Phone:816-824-9690
Mailing Address - Fax:
Practice Address - Street 1:6624 ROYAL ST
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:MO
Practice Address - Zip Code:64068-8711
Practice Address - Country:US
Practice Address - Phone:816-824-9690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-08
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008015663111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty