=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497853154
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSSELL DAVID MIKLOS DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 01/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4550 LIBERTY AVE SUITE 100
-----------------------------------------------------
City | VERMILION
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44089-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-967-5545
-----------------------------------------------------
Fax | 440-967-5546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 413
-----------------------------------------------------
City | VERMILION
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44089-0413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3273
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------