Provider Demographics
NPI:1841407616
Name:RUSSO, LEE DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:DAVID
Last Name:RUSSO
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 1:1175 FOLLY RD STE E
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4130
Mailing Address - Country:US
Mailing Address - Phone:843-225-1236
Mailing Address - Fax:843-225-1237
Practice Address - Street 1:1175 FOLLY RD STE E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-4130
Practice Address - Country:US
Practice Address - Phone:843-225-1236
Practice Address - Fax:843-225-1237
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3605111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor