Healthcare Provider Details

I. General information

NPI: 1649537168
Provider Name (Legal Business Name): CHRISTINE ANN RUSSO DPT, PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2012
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4870 BARRANCA PKWY #340
IRVINE CA
92604-4709
US

IV. Provider business mailing address

4870 BARRANCA PKWY #340
IRVINE CA
92604-4709
US

V. Phone/Fax

Practice location:
  • Phone: 949-653-7848
  • Fax:
Mailing address:
  • Phone: 949-653-7848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number38747
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: