Provider Demographics
NPI:1962656777
Name:RUSSELL CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:RUSSELL CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR. OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-604-5761
Mailing Address - Street 1:2161 W TERRA LN
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-2366
Mailing Address - Country:US
Mailing Address - Phone:636-887-9003
Mailing Address - Fax:636-327-6090
Practice Address - Street 1:2161 W TERRA LN
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-2366
Practice Address - Country:US
Practice Address - Phone:636-887-9003
Practice Address - Fax:636-327-6090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008002546111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty