Provider Demographics
NPI:1104923168
Name:WAHLEN, RUSSELL S (DC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
Last Name:WAHLEN
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 1:1276 WALL AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-5657
Mailing Address - Country:US
Mailing Address - Phone:801-337-4000
Mailing Address - Fax:801-337-4002
Practice Address - Street 1:1276 WALL AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-5657
Practice Address - Country:US
Practice Address - Phone:801-337-4000
Practice Address - Fax:801-337-4002
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT346009-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005714302Medicare ID - Type Unspecified
UTU77156Medicare UPIN