MEDICARE: MR. RUSSELL D SEAGAL 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	111NS0005X	Sports Physician Chiropractor	19979	CA

General Provider Information

NPI Number	:	1366651986
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUSSELL D SEAGAL D.C.

Provider Business Mailing Address
First Line	:	26733 OAK GARDEN CT
Second Line	:
City	:	NEWHALL
State	:	CA
Zip	:	91321-1434
Country	:	US
Telephone Number	:	818-681-4889
Fax Number	:

Provider Business Practice Location Address
First Line	:	801 S FLOWER ST
Second Line	:	SUITE 204
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-4625
Country	:	US
Telephone Number	:	213-481-7026
Fax Number	:	213-623-9985

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

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/08/2007

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