Provider Demographics
NPI:1952635328
Name:RUSSO, CARL JAMES JR (DC STUDENT)
Entity type:Individual
Prefix:MR
First Name:CARL
Middle Name:JAMES
Last Name:RUSSO
Suffix:JR
Gender:M
Credentials:DC STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6712 164TH ST
Mailing Address - Street 2:1D
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-3172
Mailing Address - Country:US
Mailing Address - Phone:917-568-8617
Mailing Address - Fax:
Practice Address - Street 1:24825 NORTHERN BLVD
Practice Address - Street 2:2D
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1211
Practice Address - Country:US
Practice Address - Phone:917-568-8617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-01
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011856-1111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation