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General NPI Number Information
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NPI Number | 1316084965
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Entity Type | Individual
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Provider Name | MANDY R RUSSELL O.D.
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Gender | Female
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 05/13/2011
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Provider Practice Location Address
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Address Line | 650 LINDEN ST SUITE 5
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City | BIG RAPIDS
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State | MI
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Zip | 49307-1879
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Country | US
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Telephone | 231-796-0010
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Fax | 231-796-2496
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Provider Business Mailing Address
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Address Line | 20665 BLUE FOX WAY
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City | HOWARD CITY
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State | MI
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Zip | 49329
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Country | US
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Telephone | 231-340-0112
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 4901004360
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License Number State | MI
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