Basic Information
| Provider Information | |||||||||
| NPI: | 1164868006 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEAN RUSSELL, O.M.D., PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5621 RAVEN HORSE DR | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891312070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025969595 | ||||||||
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| Practice Location | |||||||||
| Address1: | 129 W LAKE MEAD PKWY STE 2 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890157055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025646712 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2013 | ||||||||
| LastUpdateDate: | 05/20/2013 | ||||||||
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| AuthorizedOfficialLastName: | RUSSELL | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7025969595 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | 1042 | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Acupuncturist |
No ID Information.