Provider Demographics
NPI:1336183904
Name:RUSSELL, ERIC GLENN (DC)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:GLENN
Last Name:RUSSELL
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 1:1205 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:TX
Mailing Address - Zip Code:75428-2613
Mailing Address - Country:US
Mailing Address - Phone:903-886-3100
Mailing Address - Fax:903-886-3177
Practice Address - Street 1:1205 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:TX
Practice Address - Zip Code:75428-2613
Practice Address - Country:US
Practice Address - Phone:903-886-3100
Practice Address - Fax:903-886-3177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9291111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609779Medicare ID - Type Unspecified