Healthcare Provider Details

I. General information

NPI: 1700791050
Provider Name (Legal Business Name): BRANDON RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1351 OLD FREEHOLD RD
TOMS RIVER NJ
08753-2775
US

IV. Provider business mailing address

14206 W REMINGTON CT
WICHITA KS
67235-7533
US

V. Phone/Fax

Practice location:
  • Phone: 732-240-0090
  • Fax:
Mailing address:
  • Phone: 316-252-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number14-04185
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: