Provider Demographics
NPI:1962587493
Name:RUSSELL, ROBB (DC)
Entity type:Individual
Prefix:DR
First Name:ROBB
Middle Name:
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 1:3332 KALLIN AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-4207
Mailing Address - Country:US
Mailing Address - Phone:562-421-5588
Mailing Address - Fax:
Practice Address - Street 1:3311 E WILLOW ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2310
Practice Address - Country:US
Practice Address - Phone:562-424-4976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14749111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT17879Medicare UPIN
CADC014749Medicare ID - Type Unspecified