MEDICARE: DR. MARK DALE 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	5912	TX
2	111N00000X	Chiropractor	1894	NM
3	111N00000X	Chiropractor	928	MT
4	111N00000X	Chiropractor	2622	OK

General Provider Information

NPI Number	:	1689671315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK DALE RUSSELL D.C.

Provider Business Mailing Address
First Line	:	5309 44TH ST
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79414-1321
Country	:	US
Telephone Number	:	806-792-4041
Fax Number	:

Provider Business Practice Location Address
First Line	:	5309 44TH ST
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79414-1321
Country	:	US
Telephone Number	:	806-792-4041
Fax Number	:

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	04/01/2014

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