Provider Demographics
NPI:1871782409
Name:RUSSELL E. ST. CLAIR, D.C., LLC
Entity type:Organization
Organization Name:RUSSELL E. ST. CLAIR, D.C., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ST.CLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-352-6172
Mailing Address - Street 1:1250 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2664
Mailing Address - Country:US
Mailing Address - Phone:419-352-6172
Mailing Address - Fax:419-352-8633
Practice Address - Street 1:1250 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2664
Practice Address - Country:US
Practice Address - Phone:419-352-6172
Practice Address - Fax:419-352-8633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH412111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========001OtherMMO
=========OtherTIN
=========00OtherBWC
T46332Medicare UPIN
OH9325291Medicare PIN