Provider Demographics
NPI:1912723776
Name:RUSSELL PHYSICAL THERAPY
Entity type:Organization
Organization Name:RUSSELL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALTON
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:318-282-5468
Mailing Address - Street 1:324 PULLTIGHT RD
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263-9187
Mailing Address - Country:US
Mailing Address - Phone:318-282-5468
Mailing Address - Fax:
Practice Address - Street 1:208 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263-2557
Practice Address - Country:US
Practice Address - Phone:318-282-5468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-26
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty