Provider Demographics
NPI:1336344316
Name:DAVIS, RUSSELL ALLEN (LAC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:ALLEN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6135 ACORN ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-4006
Mailing Address - Country:US
Mailing Address - Phone:619-895-6751
Mailing Address - Fax:619-287-2239
Practice Address - Street 1:6135 ACORN ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-4006
Practice Address - Country:US
Practice Address - Phone:619-895-6751
Practice Address - Fax:619-287-2239
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6838171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist