Healthcare Provider Details

I. General information

NPI: 1730467580
Provider Name (Legal Business Name): SHARON RUSSELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ROUTE 12 OLD CRYSTAL ROAD ON LEFT
FORT DEFIANCE AZ
86504
US

IV. Provider business mailing address

POST OFFICE BOX 87
FORT DEFIANCE AZ
86504
US

V. Phone/Fax

Practice location:
  • Phone: 505-713-2649
  • Fax: 180-096-7431
Mailing address:
  • Phone: 505-713-2649
  • Fax: 180-096-7431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: SHARON LYNN RUSSELL
Title or Position: OWNER/HUMAN RESOURCES
Credential:
Phone: 505-713-2649