Healthcare Provider Details

I. General information

NPI: 1669589578
Provider Name (Legal Business Name): RUSSELL P TERI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N FLAGLER DR STE 1
WEST PALM BEACH FL
33401-3713
US

IV. Provider business mailing address

5840 CORPORATE WAY STE 101
WEST PALM BEACH FL
33407-2040
US

V. Phone/Fax

Practice location:
  • Phone: 561-432-0111
  • Fax:
Mailing address:
  • Phone: 561-432-0111
  • Fax: 561-622-4324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT20842
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPT20842
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: