Healthcare Provider Details

I. General information

NPI: 1336699651
Provider Name (Legal Business Name): CECILIA RUSSELL RCR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2016
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 GOBBLER CT
BOWLING GREEN KY
42101-7429
US

IV. Provider business mailing address

207 GOBBLER CT
BOWLING GREEN KY
42101-7429
US

V. Phone/Fax

Practice location:
  • Phone: 270-791-3397
  • Fax: 270-935-5299
Mailing address:
  • Phone: 270-791-3397
  • Fax: 270-935-5299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number9804744
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: