Provider Demographics
NPI:1801206172
Name:RUSSELL, BRENT DA SILVA (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:DA SILVA
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 1:4082 NANCY CREEK WAY NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1738
Mailing Address - Country:US
Mailing Address - Phone:404-317-2842
Mailing Address - Fax:
Practice Address - Street 1:4082 NANCY CREEK WAY NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1738
Practice Address - Country:US
Practice Address - Phone:404-317-2842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2062111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor