Healthcare Provider Details

I. General information

NPI: 1023606076
Provider Name (Legal Business Name): NICHOLAS BRYAN RUSSELL DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 SWAMP PIKE # 100
GILBERTSVILLE PA
19525-9307
US

IV. Provider business mailing address

1027 INGRAMS WAY
TELFORD PA
18969-1379
US

V. Phone/Fax

Practice location:
  • Phone: 610-327-3363
  • Fax:
Mailing address:
  • Phone: 267-281-0665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC011597
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: