Provider Demographics
NPI:1700186277
Name:MEAD, RUSSELL ERIC (DC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ERIC
Last Name:MEAD
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 1:4100 M 139
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8672
Mailing Address - Country:US
Mailing Address - Phone:269-408-0303
Mailing Address - Fax:269-408-0083
Practice Address - Street 1:4100 M 139
Practice Address - Street 2:SUITE 112
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8672
Practice Address - Country:US
Practice Address - Phone:269-408-0303
Practice Address - Fax:269-408-0083
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009696111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor