MEDICARE: DALTON LEE 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	11681	LA

General Provider Information

NPI Number	:	1891558789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALTON LEE RUSSELL

Provider Business Mailing Address
First Line	:	324 PULLTIGHT RD
Second Line	:
City	:	OAK GROVE
State	:	LA
Zip	:	71263-9187
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8649 HIGHWAY 165 N STE 5
Second Line	:
City	:	MONROE
State	:	LA
Zip	:	71203-8965
Country	:	US
Telephone Number	:	318-235-9326
Fax Number	:	318-267-0131

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

Provider Enumeration Date	:	02/02/2024
Last Update Date	:	02/02/2024

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Directions to “ DALTON LEE RUSSELL ” Practice Location

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