Provider Demographics
NPI:1639369291
Name:DEREK D. RUSSELL, D.C., INC.
Entity Type:Organization
Organization Name:DEREK D. RUSSELL, D.C., INC.
Other - Org Name:NIMMO WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:DUNCAN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-427-7690
Mailing Address - Street 1:2125 MCCOMAS WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-3986
Mailing Address - Country:US
Mailing Address - Phone:757-427-7690
Mailing Address - Fax:757-427-7692
Practice Address - Street 1:2125 MCCOMAS WAY
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-3986
Practice Address - Country:US
Practice Address - Phone:757-427-7690
Practice Address - Fax:757-427-7692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104555920111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00V075D21Medicare PIN
VAU94047Medicare UPIN