Healthcare Provider Details

I. General information

NPI: 1649618224
Provider Name (Legal Business Name): RUSSELL LAWRENCE GOURLIE D.P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 06/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 N TENAYA WAY STE 180
LAS VEGAS NV
89128-1110
US

IV. Provider business mailing address

2650 N TENAYA WAY STE 180
LAS VEGAS NV
89128-1110
US

V. Phone/Fax

Practice location:
  • Phone: 702-240-2952
  • Fax: 702-243-0482
Mailing address:
  • Phone: 702-240-2952
  • Fax: 702-243-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2872
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: