Provider Demographics
NPI:1386724656
Name:RUSSELL, SCOTT ALFONSO
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ALFONSO
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 1:23560 CRENSHAW BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5233
Mailing Address - Country:US
Mailing Address - Phone:310-784-2366
Mailing Address - Fax:310-517-0889
Practice Address - Street 1:23560 CRENSHAW BLVD
Practice Address - Street 2:STE 103
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5233
Practice Address - Country:US
Practice Address - Phone:310-784-2366
Practice Address - Fax:310-517-0889
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22163225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ02708ZOtherBLUE SHIELD