Provider Demographics
NPI:1245262328
Name:REDD, RUSS C (DC)
Entity type:Individual
Prefix:
First Name:RUSS
Middle Name:C
Last Name:REDD
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 1:1269 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-9282
Mailing Address - Country:US
Mailing Address - Phone:919-556-2014
Mailing Address - Fax:919-556-0996
Practice Address - Street 1:1269 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-9282
Practice Address - Country:US
Practice Address - Phone:919-556-2014
Practice Address - Fax:919-556-0996
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3405111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC681277OtherACN
NCPHCSOther9400767
NC561294023OtherTAX ID#
NC085WCOtherBLUE CROSS BLUE SHIELD/NC
NCV07403Medicare UPIN
NC561294023OtherTAX ID#