Healthcare Provider Details

I. General information

NPI: 1376323220
Provider Name (Legal Business Name): REX RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2023
Last Update Date: 09/28/2023
Certification Date: 09/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 NORTH MAIN
AUGUSTA AR
72012
US

IV. Provider business mailing address

202 N PEAR ST
SEARCY AR
72143-5273
US

V. Phone/Fax

Practice location:
  • Phone: 870-347-2600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4861
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: