Provider Demographics
NPI:1093993214
Name:RUSSELL, TRAVIS ALAN (DC)
Entity type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:ALAN
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 1:2625 BUTTERFIELD RD
Mailing Address - Street 2:SUITE 301N
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1234
Mailing Address - Country:US
Mailing Address - Phone:630-320-6400
Mailing Address - Fax:630-701-1007
Practice Address - Street 1:13316 VILLAGE GREEN DR
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-8027
Practice Address - Country:US
Practice Address - Phone:847-802-8446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011483111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor