Provider Demographics
NPI:1881952364
Name:GABRIEL RUSSO CHIROPRACTOR INC
Entity type:Organization
Organization Name:GABRIEL RUSSO CHIROPRACTOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GABRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:831-713-5172
Mailing Address - Street 1:2495 OLD MIDDLEFIELD WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-2316
Mailing Address - Country:US
Mailing Address - Phone:831-713-5172
Mailing Address - Fax:
Practice Address - Street 1:2495 OLD MIDDLEFIELD WAY
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-2316
Practice Address - Country:US
Practice Address - Phone:831-713-5172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC19969111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty