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General NPI Number Information
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NPI Number | 1952635328
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Entity Type | Individual
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Provider Name | CARL JAMES RUSSO JR. DC STUDENT
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Gender | Male
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Dates
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Enumeration Date | 10/01/2009
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Last Update Date | 07/22/2011
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Provider Practice Location Address
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Address Line | 24825 NORTHERN BLVD 2D
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City | LITTLE NECK
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State | NY
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Zip | 11362-1211
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Country | US
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Telephone | 917-568-8617
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Fax |
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Provider Business Mailing Address
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Address Line | 6712 164TH ST 1D
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City | FRESH MEADOWS
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State | NY
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Zip | 11365-3172
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Country | US
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Telephone | 917-568-8617
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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 | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | X011856-1
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License Number State | NY
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