Healthcare Provider Details

I. General information

NPI: 1174046874
Provider Name (Legal Business Name): RUSSELL THOMPSON CHIROPRACTIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 CAMINO DE LOS MARES, STE. 104
SAN CLEMENTE CA
92672
US

IV. Provider business mailing address

629 CAMINO DE LOS MARES STE 104
SAN CLEMENTE CA
92673-2829
US

V. Phone/Fax

Practice location:
  • Phone: 949-240-1334
  • Fax: 949-240-4434
Mailing address:
  • Phone: 949-240-1334
  • Fax: 949-240-4434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberDC31976
License Number StateCA

VIII. Authorized Official

Name: CATHY STABLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 949-240-1334