Provider Demographics
NPI:1528503083
Name:FARNSWORTH, RUSSELL TAYLOR (DPT)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:TAYLOR
Last Name:FARNSWORTH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 E CHUBBUCK RD
Mailing Address - Street 2:STE A
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2085
Mailing Address - Country:US
Mailing Address - Phone:208-417-0011
Mailing Address - Fax:888-437-2431
Practice Address - Street 1:265 E CHUBBUCK RD
Practice Address - Street 2:STE A
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2085
Practice Address - Country:US
Practice Address - Phone:208-417-0011
Practice Address - Fax:888-437-2431
Is Sole Proprietor?:No
Enumeration Date:2016-12-19
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60684082225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist