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NPI Code Detail

MEDICARE: RUSSELL SIMMONS

MEDICARE: RUSSELL SIMMONS
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
1225200000XPhysical Therapy AssistantA-1331NV

General Provider Information

NPI Number : 1609582576
Entity Type Code : Individual
Provider Name (Legal Business Name) : RUSSELL SIMMONS
Provider Business Mailing Address
First Line : 8777 W MAULE AVE UNIT 2012
Second Line :
City : LAS VEGAS
State : NV
Zip : 89148-4874
Country : US
Telephone Number : 631-404-2829
Fax Number :
Provider Business Practice Location Address
First Line : 1225 TRIUMPH CT
Second Line :
City : LAS VEGAS
State : NV
Zip : 89117-7122
Country : US
Telephone Number : 248-930-2554
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/25/2023
Last Update Date : 01/25/2023

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Directions to “ RUSSELL SIMMONS ” Practice Location

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