Healthcare Provider Details

I. General information

NPI: 1053393884
Provider Name (Legal Business Name): JOSEPH LOUIS RUSSO CHIROPRACTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARK BLVD
MASSAPEQUA PARK NY
11762-2742
US

IV. Provider business mailing address

500 PARK BLVD
MASSAPEQUA PARK NY
11762-3042
US

V. Phone/Fax

Practice location:
  • Phone: 516-798-8363
  • Fax: 516-798-8586
Mailing address:
  • Phone: 516-798-8363
  • Fax: 516-798-8586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberX00003447
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: