=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053135988
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUSSELL J GRANT II PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2024
-----------------------------------------------------
Last Update Date | 11/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 LAFAYETTE ST STE 105
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95050-4966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-293-7794
-----------------------------------------------------
Fax | 408-638-2503
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 LAFAYETTE ST STE 105
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95050-4966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-293-7794
-----------------------------------------------------
Fax | 408-638-2503
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 307133
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 307133
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------