Provider Demographics
NPI:1326744616
Name:RUSSO PHYSICAL THERAPY A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:RUSSO PHYSICAL THERAPY A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:714-335-7946
Mailing Address - Street 1:1442 E LINCOLN AVE STE 168
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-1934
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 EAST RIVERBOAT WAY
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865
Practice Address - Country:US
Practice Address - Phone:714-335-7946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-07
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty