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General NPI Number Information
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NPI Number | 1811014269
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Entity Type | Individual
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Provider Name | VINCE R RUSSO LPN
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Gender | Male
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Dates
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Enumeration Date | 03/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 4305 GYPSY LN
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City | COLLEGEVILLE
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State | PA
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Zip | 19426-1165
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Country | US
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Telephone | 484-902-8223
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Fax | 267-354-6899
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Provider Business Mailing Address
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Address Line | 4305 GYPSY LN
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City | COLLEGEVILLE
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State | PA
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Zip | 19426-1165
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Country | US
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Telephone | 484-902-8223
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Fax | 267-354-6899
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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 | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | PN262002
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License Number State | PA
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