=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285145177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL CHIROPRACTIC & ACUPUNCTURE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2017
-----------------------------------------------------
Last Update Date | 10/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10793 TIERRASANTA BLVD STE A
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92124-2629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-573-1505
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10793 TIERRASANTA BLVD STE A
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92124-2629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ CHIROPRACTOR
-----------------------------------------------------
Name | CHANTAL RUSSELL
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 858-573-1505
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number | AC11156
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | DC29891
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------