Provider Demographics
NPI:1487961322
Name:RUSSELL, TY D (DC)
Entity type:Individual
Prefix:DR
First Name:TY
Middle Name:D
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 1:207 ATLANTA STREET S.E.
Mailing Address - Street 2:
Mailing Address - City:GRAVETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72736
Mailing Address - Country:US
Mailing Address - Phone:479-787-7555
Mailing Address - Fax:479-787-7444
Practice Address - Street 1:207 ATLANTA STREET S.E.
Practice Address - Street 2:
Practice Address - City:GRAVETTE
Practice Address - State:AR
Practice Address - Zip Code:72736
Practice Address - Country:US
Practice Address - Phone:479-787-7555
Practice Address - Fax:479-787-7444
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR15,726111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor