Provider Demographics
NPI:1134594229
Name:RUSSELL B ALLISON
Entity type:Organization
Organization Name:RUSSELL B ALLISON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:PARIS
Authorized Official - Last Name:TENCLEVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-890-9292
Mailing Address - Street 1:PO BOX 1146
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-1146
Mailing Address - Country:US
Mailing Address - Phone:479-890-9292
Mailing Address - Fax:479-890-6962
Practice Address - Street 1:5395 W ASH ST STE 1
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72858-9228
Practice Address - Country:US
Practice Address - Phone:479-219-5034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR04D2089584OtherCLIA