Healthcare Provider Details

I. General information

NPI: 1750753182
Provider Name (Legal Business Name): ZACHARY RUSSELL ATC, LAT, CSCS, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2015
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 JENNINGS MILL ROAD BUILDING 300, SUITE 110
WATKINSVILLE GA
30677
US

IV. Provider business mailing address

5883 N NEVADA AVE 324
COLORADO SPRINGS CO
80918-3507
US

V. Phone/Fax

Practice location:
  • Phone: 706-613-5880
  • Fax: 706-613-5880
Mailing address:
  • Phone: 678-481-6519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0001416
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberAT003715
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: