Healthcare Provider Details

I. General information

NPI: 1477554665
Provider Name (Legal Business Name): RUSSELL MORELAND DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 N LAGRANGE RD
FRANKFORT IL
60423-1347
US

IV. Provider business mailing address

631 N LA GRANGE RD
FRANKFORT IL
60423-1347
US

V. Phone/Fax

Practice location:
  • Phone: 815-464-8450
  • Fax: 815-464-8451
Mailing address:
  • Phone: 815-464-8450
  • Fax: 815-464-8451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: