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General NPI Number Information
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NPI Number | 1215130828
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Entity Type | Individual
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Provider Name | RUSSELL THOMAS BAKER JR. MS, MS, ATC
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Gender | Male
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Dates
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Enumeration Date | 06/09/2007
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Last Update Date | 12/02/2009
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Provider Practice Location Address
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Address Line | 8432 MAGNOLIA AVE
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City | RIVERSIDE
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State | CA
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Zip | 92504-3206
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Country | US
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Telephone | 239-560-7854
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Fax |
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Provider Business Mailing Address
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Address Line | 7450 NORTHROP DR APT 94
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City | RIVERSIDE
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State | CA
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Zip | 92508-5005
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Country | US
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Telephone | 239-560-7854
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State |
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