Provider Demographics
NPI:1447123310
Name:RUSSELL, CAREY LAVON
Entity type:Individual
Prefix:MR
First Name:CAREY
Middle Name:LAVON
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 MILL ST
Mailing Address - Street 2:
Mailing Address - City:LOYALTON
Mailing Address - State:CA
Mailing Address - Zip Code:96118-5798
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:704 MILL ST
Practice Address - Street 2:
Practice Address - City:LOYALTON
Practice Address - State:CA
Practice Address - Zip Code:96118-5798
Practice Address - Country:US
Practice Address - Phone:530-993-6746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist