Provider Demographics
NPI:1023606076
Name:RUSSELL, NICHOLAS BRYAN (DC)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:BRYAN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 INGRAMS WAY
Mailing Address - Street 2:
Mailing Address - City:TELFORD
Mailing Address - State:PA
Mailing Address - Zip Code:18969-1379
Mailing Address - Country:US
Mailing Address - Phone:267-281-0665
Mailing Address - Fax:
Practice Address - Street 1:1810 SWAMP PIKE # 100
Practice Address - Street 2:
Practice Address - City:GILBERTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:19525-9307
Practice Address - Country:US
Practice Address - Phone:610-327-3363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC011597111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor