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General NPI Number Information
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NPI Number | 1497769210
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Entity Type | Individual
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Provider Name | RUSSELL SHANNON HUMPHRIES DC
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Gender | Male
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Dates
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Enumeration Date | 07/28/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4343 RIDGEWOOD AVENUE SUITE B
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City | PORT ORANGE
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State | FL
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Zip | 32127
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Country | US
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Telephone | 386-767-2727
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Fax | 386-767-6674
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Provider Business Mailing Address
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Address Line | 4343 RIDGEWOOD AVENUE SUITE B
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City | PORT ORANGE
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State | FL
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Zip | 32127
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Country | US
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Telephone | 386-767-2727
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Fax | 386-767-6674
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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 | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CH3773
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License Number State | FL
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