Healthcare Provider Details

I. General information

NPI: 1245295021
Provider Name (Legal Business Name): RUSSELL L. PALMER JR, R.T., B.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 WHITE SPAR RD
PRESCOTT AZ
86303-4236
US

IV. Provider business mailing address

1045 SCOTT DR
PRESCOTT AZ
86301-1731
US

V. Phone/Fax

Practice location:
  • Phone: 928-777-9064
  • Fax: 928-777-9183
Mailing address:
  • Phone: 928-777-9064
  • Fax: 928-777-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335V00000X
TaxonomyPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
License NumberCRT-5873
License Number StateAZ

VIII. Authorized Official

Name: MR. RUSSELL LEON PALMER JR.
Title or Position: OWNER
Credential: R.T.,B.S.
Phone: 928-777-9064