=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083704225
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRETT RUSSELL PHYSICAL THERAPY AND FITNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 10/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 N HIGHWAY 25
-----------------------------------------------------
City | TRAVELERS REST
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29690-9388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-834-4995
-----------------------------------------------------
Fax | 864-834-4551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 N HIGHWAY 25
-----------------------------------------------------
City | TRAVELERS REST
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29690-9388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-834-4995
-----------------------------------------------------
Fax | 864-834-4551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BRETT LEE RUSSELL
-----------------------------------------------------
Credential | PT,ATC,LMT
-----------------------------------------------------
Telephone | 864-363-8119
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 2005
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------