MEDICARE: RUSSELL WELLNESS CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3166	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DF3888	OTHER	OK	PALMETTO GROUP

General Provider Information

NPI Number	:	1104010537
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELL WELLNESS CLINIC

Provider Business Mailing Address
First Line	:	2523 SE WASHINGTON BLVD.
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-8336
Country	:	US
Telephone Number	:	918-333-3363
Fax Number	:

Provider Business Practice Location Address
First Line	:	2523 SE WASHINGTON BLVD.
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-8336
Country	:	US
Telephone Number	:	918-333-3363
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. TRACY OWEN RUSSELL
Credential	:	DC
Telephone Number	:	918-333-3363

Provider Enumeration Date	:	08/29/2007
Last Update Date	:	08/10/2011

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Directions to “RUSSELL WELLNESS CLINIC ” Practice Location

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