Basic Information
Provider Information
NPI: 1003012980
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RUSSELL
FirstName: MICHAEL
MiddleName: D
NamePrefix: MR.
NameSuffix:  
Credential: PT,DPT, CSCS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 129 W LAKE MEAD PKWY
Address2: SUITE 2
City: HENDERSON
State: NV
PostalCode: 890156954
CountryCode: US
TelephoneNumber: 7025646712
FaxNumber: 7025644838
Practice Location
Address1: 129 W LAKE MEAD PKWY
Address2: SUITE 2
City: HENDERSON
State: NV
PostalCode: 890156954
CountryCode: US
TelephoneNumber: 7025646712
FaxNumber: 7025644838
Other Information
ProviderEnumerationDate: 06/26/2007
LastUpdateDate: 05/04/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X2143NVY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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