Healthcare Provider Details

I. General information

NPI: 1922493055
Provider Name (Legal Business Name): GEORGE RUSSELL PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2015
Last Update Date: 02/16/2025
Certification Date: 02/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12961 LAFAYETTE ST UNIT H
THORNTON CO
80241-3969
US

IV. Provider business mailing address

247 REMUDA LN
LAFAYETTE CO
80026-7006
US

V. Phone/Fax

Practice location:
  • Phone: 720-508-3422
  • Fax:
Mailing address:
  • Phone: 201-638-3598
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL0012394
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: