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General NPI Number Information
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NPI Number | 1750753182
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Entity Type | Individual
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Provider Name | ZACHARY RUSSELL ATC, LAT, CSCS, OTC
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Gender | Male
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Dates
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Enumeration Date | 10/26/2015
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Last Update Date | 09/27/2019
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Provider Practice Location Address
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Address Line | 1305 JENNINGS MILL ROAD BUILDING 300, SUITE 110
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City | WATKINSVILLE
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State | GA
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Zip | 30677
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Country | US
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Telephone | 706-613-5880
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Fax | 706-613-5880
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Provider Business Mailing Address
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Address Line | 5883 N NEVADA AVE 324
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City | COLORADO SPRINGS
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State | CO
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Zip | 80918-3507
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Country | US
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Telephone | 678-481-6519
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number | 0001416
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 207XX0005X
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Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
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License Number | AT003715
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License Number State | GA
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