Provider Demographics
NPI:1982607966
Name:DAVIS, RUSSELL KELSO (DC)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:KELSO
Last Name:DAVIS
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 1:318 E. MAIN ST.
Mailing Address - Street 2:NAVAL HOSPITAL
Mailing Address - City:HAVELOCK
Mailing Address - State:NC
Mailing Address - Zip Code:28532-2214
Mailing Address - Country:US
Mailing Address - Phone:252-444-3377
Mailing Address - Fax:252-444-3529
Practice Address - Street 1:318 E. MAIN ST.
Practice Address - Street 2:
Practice Address - City:HAVELOCK
Practice Address - State:NC
Practice Address - Zip Code:28532-2214
Practice Address - Country:US
Practice Address - Phone:252-444-3377
Practice Address - Fax:252-444-3529
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2801111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC616120OtherACN IDENTIFICATION #
NC7167352OtherAETNA PROVIDER #
NC0844VOtherBCBS PROVIDER #
NC890844VMedicaid
NC890844VMedicaid
NCU80827Medicare UPIN
NC890844VMedicaid