Provider Demographics
NPI:1134580806
Name:RUSSELL, SAVANNAH (LAC)
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-1904
Mailing Address - Country:US
Mailing Address - Phone:707-485-2147
Mailing Address - Fax:
Practice Address - Street 1:313 W DRAKE RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-2846
Practice Address - Country:US
Practice Address - Phone:970-472-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU.0002183171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist