MEDICARE: RUSSELL FAMILY CLINIC, LLC

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	6198	CO

General Provider Information

NPI Number	:	1811281975
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUSSELL FAMILY CLINIC, LLC

Provider Business Mailing Address
First Line	:	200 S MASON ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-2813
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 S MASON ST
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80524-2813
Country	:	US
Telephone Number	:	970-482-2053
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JOSHUA RUSSELL
Credential	:	D.C.
Telephone Number	:	970-482-2053

Provider Enumeration Date	:	06/07/2011
Last Update Date	:	06/07/2011

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