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NPI Code Detail

MEDICARE: WESLEY ALEXANDER RUSSELL II BA

MEDICARE: WESLEY ALEXANDER RUSSELL II BA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225400000XRehabilitation Practitioner

General Provider Information

NPI Number : 1568580298
Entity Type Code : Individual
Provider Name (Legal Business Name) : WESLEY ALEXANDER RUSSELL II BA
Provider Business Mailing Address
First Line : 11245 S BUDLONG AVE
Second Line :
City : LOS ANGELES
State : CA
Zip : 90044-1309
Country : US
Telephone Number : 323-755-9694
Fax Number : 323-755-9694
Provider Business Practice Location Address
First Line : 2010 E EL SEGUNDO BLVD
Second Line :
City : COMPTON
State : CA
Zip : 90222-7109
Country : US
Telephone Number : 310-637-0917
Fax Number : 310-637-0473
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/27/2007
Last Update Date : 07/08/2007

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