Healthcare Provider Details

I. General information

NPI: 1396040945
Provider Name (Legal Business Name): RUSSELL HINTON GARNER III PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 CLINTON PKWY
CLINTON MS
39056-4730
US

IV. Provider business mailing address

108 CLINTON PKWY
CLINTON MS
39056-4730
US

V. Phone/Fax

Practice location:
  • Phone: 601-926-2018
  • Fax: 601-924-9746
Mailing address:
  • Phone: 601-926-2018
  • Fax: 601-924-9746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA3976
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: