Provider Demographics
NPI:1548295025
Name:HO LEM, RUSSELL KEITH (DC)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:KEITH
Last Name:HO LEM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9014 N 23RD AVE STE 8
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-2854
Mailing Address - Country:US
Mailing Address - Phone:602-861-3339
Mailing Address - Fax:602-861-3280
Practice Address - Street 1:9014 N 23RD AVE STE 8
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-2854
Practice Address - Country:US
Practice Address - Phone:602-861-3339
Practice Address - Fax:602-861-3280
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5492111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0933310OtherBLUE CROSS BLUE SHIELD
AZ23361Medicare ID - Type Unspecified
AZAZ0933310OtherBLUE CROSS BLUE SHIELD