Provider Demographics
NPI:1609963867
Name:RUSSELL CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:RUSSELL CHIROPRACTIC, INC
Other - Org Name:RUSSELL CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:530-749-2225
Mailing Address - Street 1:905 G ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-5121
Mailing Address - Country:US
Mailing Address - Phone:530-749-2225
Mailing Address - Fax:530-479-2229
Practice Address - Street 1:905 G ST
Practice Address - Street 2:SUITE G
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5121
Practice Address - Country:US
Practice Address - Phone:530-749-2225
Practice Address - Fax:530-479-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC26585111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU77685Medicare UPIN
CADC0265850Medicare ID - Type Unspecified