Healthcare Provider Details

I. General information

NPI: 1265380737
Provider Name (Legal Business Name): KEVIN RUSSELL L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2026
Last Update Date: 03/19/2026
Certification Date: 03/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3280 ADELINE ST
BERKELEY CA
94703-2439
US

IV. Provider business mailing address

229 SCENIC AVE
PIEDMONT CA
94611-3416
US

V. Phone/Fax

Practice location:
  • Phone: 510-387-8678
  • Fax:
Mailing address:
  • Phone: 510-343-4942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC20036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: