Healthcare Provider Details

I. General information

NPI: 1982607966
Provider Name (Legal Business Name): RUSSELL KELSO DAVIS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

318 E. MAIN ST.
HAVELOCK NC
28532-2214
US

IV. Provider business mailing address

318 E. MAIN ST. NAVAL HOSPITAL
HAVELOCK NC
28532-2214
US

V. Phone/Fax

Practice location:
  • Phone: 252-444-3377
  • Fax: 252-444-3529
Mailing address:
  • Phone: 252-444-3377
  • Fax: 252-444-3529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2801
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: