Provider Demographics
NPI:1689671315
Name:RUSSELL, MARK DALE (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DALE
Last Name:RUSSELL
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 1:5309 44TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-1321
Mailing Address - Country:US
Mailing Address - Phone:806-792-4041
Mailing Address - Fax:
Practice Address - Street 1:5309 44TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-1321
Practice Address - Country:US
Practice Address - Phone:806-792-4041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5912111N00000X
NM1894111N00000X
MT928111N00000X
OK2622111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor