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General NPI Number Information
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NPI Number | 1700134046
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Entity Type | Organization
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Legal Business Name | RUSS RECOVERY IOP SERVCES- PC
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Dates
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Enumeration Date | 08/16/2012
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Last Update Date | 07/02/2014
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Provider Practice Location Address
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Address Line | 2825 TAHQUITZ CANYON WAY BLDG C
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City | PALM SPRINGS
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State | CA
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Zip | 92262
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Country | US
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Telephone | 866-484-6444
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Fax | 760-416-7709
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Provider Business Mailing Address
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Address Line | 2825 TAHQUITZ CANYON WAY BLDG C
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City | PALM SPRINGS
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State | CA
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Zip | 92262-7038
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Country | US
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Telephone | 866-484-6444
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Fax | 760-416-7709
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | KENNETH CARL RUSS
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Credential | M.D.
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Telephone | 760-416-7755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0401X
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Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
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License Number | MFC49984
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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