Healthcare Provider Details

I. General information

NPI: 1093714222
Provider Name (Legal Business Name): KERRY BRUCE RUSSELL D.C., C.C.S.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/24/2006

III. Provider practice location address

692 HANNAH AVE SUITE A
TRAVERSE CITY MI
49686-3110
US

IV. Provider business mailing address

692 HANNAH AVE SUITE A
TRAVERSE CITY MI
49686-3110
US

V. Phone/Fax

Practice location:
  • Phone: 231-947-2228
  • Fax: 231-947-2616
Mailing address:
  • Phone: 231-947-2228
  • Fax: 231-947-2616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberKR007665
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: