Healthcare Provider Details

I. General information

NPI: 1982037339
Provider Name (Legal Business Name): RUSSELL SALMON AT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2013
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 HEALTHWEST DR
DOTHAN AL
36303-2053
US

IV. Provider business mailing address

PO BOX 729
DOTHAN AL
36302-0729
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-2663
  • Fax: 334-836-2247
Mailing address:
  • Phone: 334-793-2663
  • Fax: 334-836-2247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1515
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: