Provider Demographics
NPI:1619048576
Name:ANTICO, RUSSEL VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:VINCENT
Last Name:ANTICO
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 1:7060 OAKLAND MILLS RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046-1694
Mailing Address - Country:US
Mailing Address - Phone:443-259-0235
Mailing Address - Fax:443-259-0236
Practice Address - Street 1:7060 OAKLAND MILLS RD
Practice Address - Street 2:SUITE I
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046-1694
Practice Address - Country:US
Practice Address - Phone:443-259-0235
Practice Address - Fax:443-259-0236
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01939111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor