Healthcare Provider Details

I. General information

NPI: 1831371681
Provider Name (Legal Business Name): JOHN P RUSSO, DC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 HEMPSTEAD AVE
LYNBROOK NY
11563-1617
US

IV. Provider business mailing address

20 HEMPSTEAD AVE
LYNBROOK NY
11563-1617
US

V. Phone/Fax

Practice location:
  • Phone: 516-599-2593
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberX003947
License Number StateNY

VIII. Authorized Official

Name: MRS. DIANE L O'DONOHUE
Title or Position: OFFICE MANAGER
Credential:
Phone: 516-599-2593