Provider Demographics
NPI:1083704225
Name:BRETT RUSSELL PHYSICAL THERAPY AND FITNESS LLC
Entity Type:Organization
Organization Name:BRETT RUSSELL PHYSICAL THERAPY AND FITNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT,ATC,LMT
Authorized Official - Phone:864-363-8119
Mailing Address - Street 1:600 N HIGHWAY 25
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-9388
Mailing Address - Country:US
Mailing Address - Phone:864-834-4995
Mailing Address - Fax:864-834-4551
Practice Address - Street 1:600 N HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-9388
Practice Address - Country:US
Practice Address - Phone:864-834-4995
Practice Address - Fax:864-834-4551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2005225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC9388OtherMEDICARE PTAN