Healthcare Provider Details

I. General information

NPI: 1164623864
Provider Name (Legal Business Name): RUSSO CHIROPRACTIC CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12362 EUCLID ST
GARDEN GROVE CA
92840-3308
US

IV. Provider business mailing address

12362 EUCLID ST
GARDEN GROVE CA
92840-3308
US

V. Phone/Fax

Practice location:
  • Phone: 714-534-5712
  • Fax: 714-882-7371
Mailing address:
  • Phone: 714-534-5712
  • Fax: 714-882-7371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number22452
License Number StateCA

VIII. Authorized Official

Name: DR. MICHEAL RUSSO
Title or Position: PRESIDENT
Credential: D.C. QME
Phone: 714-534-5712