Healthcare Provider Details

I. General information

NPI: 1275360232
Provider Name (Legal Business Name): RUSSELL BUNTING PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2024
Last Update Date: 09/16/2024
Certification Date: 09/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E TUOLUMNE RD
TURLOCK CA
95382-1541
US

IV. Provider business mailing address

PO BOX 342
KINGSBURG CA
93631-0342
US

V. Phone/Fax

Practice location:
  • Phone: 209-667-8409
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2181592
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number53045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: