MEDICARE: RUSSELL LAWRENCE GOURLIE D.P.T.

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
1	225100000X	Physical Therapist	2872	NV

General Provider Information

NPI Number	:	1649618224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL LAWRENCE GOURLIE D.P.T.

Provider Business Mailing Address
First Line	:	2650 N TENAYA WAY STE 180
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1110
Country	:	US
Telephone Number	:	702-240-2952
Fax Number	:	702-243-0482

Provider Business Practice Location Address
First Line	:	2650 N TENAYA WAY STE 180
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-1110
Country	:	US
Telephone Number	:	702-240-2952
Fax Number	:	702-243-0482

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2013
Last Update Date	:	06/05/2013

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Directions to “ RUSSELL LAWRENCE GOURLIE D.P.T.” Practice Location

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