Basic Information
| Provider Information | |||||||||
| NPI: | 1881967446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANUEL | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | LANDON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | B.A. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 105 SE 45TH | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 105 SE 45TH | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731293201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056344400 | ||||||||
| FaxNumber: | 4056321976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2012 | ||||||||
| LastUpdateDate: | 09/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.