MEDICARE: TAYLOR RENE RUSSELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	2018040162	MO

General Provider Information

NPI Number	:	1235774381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAYLOR RENE RUSSELL

Provider Business Mailing Address
First Line	:	1108 W LIBERTY ST
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1922
Country	:	US
Telephone Number	:	573-260-4136
Fax Number	:

Provider Business Practice Location Address
First Line	:	1108 W LIBERTY ST
Second Line	:
City	:	FARMINGTON
State	:	MO
Zip	:	63640-1922
Country	:	US
Telephone Number	:	573-260-4136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/13/2019
Last Update Date	:	11/13/2019

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Directions to “ TAYLOR RENE RUSSELL ” Practice Location

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