MEDICARE: KIMBERLY J RUSSELL P.T.

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	6220035-2401	UT
2	2251X0800X	Orthopedic Physical Therapist	35709	CA

General Provider Information

NPI Number	:	1992718837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY J RUSSELL P.T.

Provider Business Mailing Address
First Line	:	970 MONUMENT STREET
Second Line	:	SUITE 207
City	:	PACIFIC PALISADES
State	:	CA
Zip	:	90272
Country	:	US
Telephone Number	:	310-573-9553
Fax Number	:	310-573-9533

Provider Business Practice Location Address
First Line	:	135 S BARRINGTON PL
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-3305
Country	:	US
Telephone Number	:	310-472-2121
Fax Number	:	310-472-4567

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

Provider Enumeration Date	:	08/14/2006
Last Update Date	:	02/07/2011

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Directions to “ KIMBERLY J RUSSELL P.T.” Practice Location

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