Healthcare Provider Details

I. General information

NPI: 1629148044
Provider Name (Legal Business Name): RUSSELL WILLIAM WILLIAMS III DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 LOMOND CT
UTICA NY
13502-5951
US

IV. Provider business mailing address

6158 MORRIS RD
MARCY NY
13403-3311
US

V. Phone/Fax

Practice location:
  • Phone: 315-732-3400
  • Fax: 315-732-4250
Mailing address:
  • Phone: 315-525-6846
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number011274
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: