MEDICARE: DR. TRACY OWEN RUSSELL D.C.

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#

General Provider Information

NPI Number	:	1316010572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRACY OWEN RUSSELL D.C.

Provider Business Mailing Address
First Line	:	2523 SE WASHINGTON BLVD.
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-8338
Country	:	US
Telephone Number	:	918-333-3363
Fax Number	:	918-333-5539

Provider Business Practice Location Address
First Line	:	2523 SE WASHINGTON BLVD.
Second Line	:
City	:	BARTLESVILLE
State	:	OK
Zip	:	74006-8338
Country	:	US
Telephone Number	:	918-333-3363
Fax Number	:	918-333-5539

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2006
Last Update Date	:	07/09/2024

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