MEDICARE: DR. ERIC GLENN RUSSELL DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	9291	TX

General Provider Information

NPI Number	:	1336183904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC GLENN RUSSELL DC

Provider Business Mailing Address
First Line	:	1205 WASHINGTON ST
Second Line	:
City	:	COMMERCE
State	:	TX
Zip	:	75428-2613
Country	:	US
Telephone Number	:	903-886-3100
Fax Number	:	903-886-3177

Provider Business Practice Location Address
First Line	:	1205 WASHINGTON ST
Second Line	:
City	:	COMMERCE
State	:	TX
Zip	:	75428-2613
Country	:	US
Telephone Number	:	903-886-3100
Fax Number	:	903-886-3177

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	07/08/2007

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