Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111N00000X | Chiropractor | 2794 | MA |
N | 111NR0400X | Rehabilitation Chiropractor | 2794 | MA |
NPI | 1225171523 |
---|---|
Provider Name | Dr. Ezekiel William Russell |
First Address | Longmeadow, MA 01106-2322 |
Second Address | Florence, MA 01062-1499 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7763033 | CIGNA HEALTH CARE (01) | MA |