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General NPI Number Information
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NPI Number | 1891558789
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Entity Type | Individual
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Provider Name | DALTON LEE RUSSELL
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Gender | Male
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Dates
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Enumeration Date | 02/02/2024
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Last Update Date | 02/02/2024
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Provider Practice Location Address
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Address Line | 8649 HIGHWAY 165 N STE 5
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City | MONROE
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State | LA
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Zip | 71203-8965
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Country | US
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Telephone | 318-235-9326
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Fax | 318-267-0131
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Provider Business Mailing Address
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Address Line | 324 PULLTIGHT RD
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City | OAK GROVE
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State | LA
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Zip | 71263-9187
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Country | US
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Telephone |
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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 | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 11681
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License Number State | LA
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