MEDICARE: RUSSELL KEVIN BOULDIN R.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	0847	NV

General Provider Information

NPI Number	:	1770551426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL KEVIN BOULDIN R.P.T

Provider Business Mailing Address
First Line	:	9499 W CHARLESTON BLVD
Second Line	:	SUITE 220
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-7147
Country	:	US
Telephone Number	:	702-933-9394
Fax Number	:	702-933-9395

Provider Business Practice Location Address
First Line	:	9499 W CHARLESTON BLVD
Second Line	:	SUITE 220
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-7147
Country	:	US
Telephone Number	:	702-933-9394
Fax Number	:	702-933-9395

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

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	05/21/2008

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