Provider Demographics
NPI:1265542781
Name:LANE, CHARLES RUSSELL (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RUSSELL
Last Name:LANE
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 1:2800 FORESTWOOD DR STE 102
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76006-2700
Mailing Address - Country:US
Mailing Address - Phone:817-649-9800
Mailing Address - Fax:817-649-9803
Practice Address - Street 1:2800 FORESTWOOD DR STE 102
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76006-2700
Practice Address - Country:US
Practice Address - Phone:817-649-9800
Practice Address - Fax:817-649-9803
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC7158111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00676KOtherGROUP
TX1538376322OtherGROUP NPI
TX80281NMedicare PIN
TXU64221Medicare UPIN