Provider Demographics
NPI:1871606111
Name:FLACCO, RUSSELL J (DC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:FLACCO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:252 W SWAMP RD
Mailing Address - Street 2:UNIT 57
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-2465
Mailing Address - Country:US
Mailing Address - Phone:215-348-9551
Mailing Address - Fax:215-345-9078
Practice Address - Street 1:252 W SWAMP RD
Practice Address - Street 2:UNIT 57
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-2465
Practice Address - Country:US
Practice Address - Phone:215-348-9551
Practice Address - Fax:215-345-9078
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PADC001396L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T29049Medicare UPIN
PA115806Medicare PIN