Provider Demographics
NPI:1821141862
Name:RUSSELL CHIROPRACTIC CARE, SC
Entity Type:Organization
Organization Name:RUSSELL CHIROPRACTIC CARE, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-530-0506
Mailing Address - Street 1:477 S SPRING RD
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3857
Mailing Address - Country:US
Mailing Address - Phone:630-530-0506
Mailing Address - Fax:630-530-0854
Practice Address - Street 1:477 S SPRING RD
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-3857
Practice Address - Country:US
Practice Address - Phone:630-530-0506
Practice Address - Fax:630-530-0854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-21
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006311111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210807Medicare ID - Type UnspecifiedGROUP NUMBER
IL210807OtherPTAN
IL210807Medicare ID - Type UnspecifiedGROUP NUMBER