Healthcare Provider Details

I. General information

NPI: 1700205432
Provider Name (Legal Business Name): RUSSELL RAY RUTLEDGE III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2014
Last Update Date: 04/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 HIGHWAY 528 NW STE 106
ALBUQUERQUE NM
87114-8919
US

IV. Provider business mailing address

3615 HIGHWAY 528 NW STE 106
ALBUQUERQUE NM
87114-8919
US

V. Phone/Fax

Practice location:
  • Phone: 505-899-4334
  • Fax: 505-792-4236
Mailing address:
  • Phone: 505-899-4334
  • Fax: 505-792-4236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-0959
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: