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General NPI Number Information
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NPI Number | 1255149753
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Entity Type | Individual
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Provider Name | RANDALL LOYD RUSSELL PT
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Gender | Male
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Dates
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Enumeration Date | 12/30/2024
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Last Update Date | 12/31/2024
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Provider Practice Location Address
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Address Line | 5958 SAINT BERNARD AVE
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City | NEW ORLEANS
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State | LA
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Zip | 70122-1324
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Country | US
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Telephone | 601-206-9195
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Fax |
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Provider Business Mailing Address
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Address Line | 13 NORTHTOWN DR STE 110
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City | JACKSON
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State | MS
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Zip | 39211-3047
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Country | US
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Telephone | 601-206-9195
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Fax | 601-957-8391
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 05073
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License Number State | LA
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