Healthcare Provider Details

I. General information

NPI: 1013335421
Provider Name (Legal Business Name): RUSSELL HEALTH AND WELLNESS CENTER, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 S SPRING RD
ELMHURST IL
60126-3857
US

IV. Provider business mailing address

477 S SPRING RD
ELMHURST IL
60126-3857
US

V. Phone/Fax

Practice location:
  • Phone: 630-530-0506
  • Fax: 630-530-0854
Mailing address:
  • Phone: 630-530-0506
  • Fax: 630-530-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038006311
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038006311
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number038006311
License Number StateIL

VIII. Authorized Official

Name: DR. BRIAN J RUSSELL
Title or Position: PRESIDENT
Credential: DC
Phone: 630-530-0506