Provider Demographics
NPI:1174528749
Name:FASOLINO, RUSS F (DC)
Entity type:Individual
Prefix:DR
First Name:RUSS
Middle Name:F
Last Name:FASOLINO
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:PO BOX 772583
Mailing Address - Street 2:320 OAK STREET
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80477-2583
Mailing Address - Country:US
Mailing Address - Phone:970-870-8888
Mailing Address - Fax:970-870-3076
Practice Address - Street 1:320 OAK STREET
Practice Address - Street 2:
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80477
Practice Address - Country:US
Practice Address - Phone:970-870-8888
Practice Address - Fax:970-870-3076
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2475111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC48563Medicare PIN