Healthcare Provider Details

I. General information

NPI: 1700134046
Provider Name (Legal Business Name): RUSS RECOVERY IOP SERVCES- PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 TAHQUITZ CANYON WAY BLDG C
PALM SPRINGS CA
92262
US

IV. Provider business mailing address

2825 TAHQUITZ CANYON WAY BLDG C
PALM SPRINGS CA
92262-7038
US

V. Phone/Fax

Practice location:
  • Phone: 866-484-6444
  • Fax: 760-416-7709
Mailing address:
  • Phone: 866-484-6444
  • Fax: 760-416-7709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License NumberMFC49984
License Number StateCA

VIII. Authorized Official

Name: KENNETH CARL RUSS
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 760-416-7755