Provider Demographics
NPI:1770956633
Name:RUSS FAMILY CHIROPRACTIC LLC
Entity type:Organization
Organization Name:RUSS FAMILY CHIROPRACTIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:RUSS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-754-6136
Mailing Address - Street 1:1717 NE 42ND AVE
Mailing Address - Street 2:#3200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1569
Mailing Address - Country:US
Mailing Address - Phone:503-688-1219
Mailing Address - Fax:503-388-6168
Practice Address - Street 1:1717 NE 42ND AVE
Practice Address - Street 2:#3200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1569
Practice Address - Country:US
Practice Address - Phone:503-688-1219
Practice Address - Fax:503-388-6168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-01
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3117111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty