Provider Demographics
NPI:1619175288
Name:ANDERSON, RUSSELL N (DC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:N
Last Name:ANDERSON
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 1:20825 SOUTH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-6438
Mailing Address - Country:US
Mailing Address - Phone:661-205-5373
Mailing Address - Fax:661-823-7483
Practice Address - Street 1:20825 SOUTH ST
Practice Address - Street 2:SUITE A
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-6438
Practice Address - Country:US
Practice Address - Phone:661-205-5373
Practice Address - Fax:661-823-7483
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20106111NI0013X
NVB-866111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical Examiner