=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245295021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL L. PALMER JR, R.T., B.S.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2006
-----------------------------------------------------
Last Update Date | 06/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 WHITE SPAR RD
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86303-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-777-9064
-----------------------------------------------------
Fax | 928-777-9183
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1045 SCOTT DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-777-9064
-----------------------------------------------------
Fax | 928-777-9183
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. RUSSELL LEON PALMER JR.
-----------------------------------------------------
Credential | R.T.,B.S.
-----------------------------------------------------
Telephone | 928-777-9064
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335V00000X
-----------------------------------------------------
Taxonomy Name | Portable X-ray and/or Other Portable Diagnostic Imaging Supplier
-----------------------------------------------------
License Number | CRT-5873
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------