=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821474198
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBB RUSSELL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2015
-----------------------------------------------------
Last Update Date | 08/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 W 16TH STREET
-----------------------------------------------------
City | SALIDA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-539-9080
-----------------------------------------------------
Fax | 719-539-6122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 W 16TH STREET
-----------------------------------------------------
City | SALIDA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-539-9080
-----------------------------------------------------
Fax | 719-539-6122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PTL.0008074
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------