Provider Demographics
NPI:1568580298
Name:RUSSELL, WESLEY ALEXANDER II (BA)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:ALEXANDER
Last Name:RUSSELL
Suffix:II
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11245 S BUDLONG AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-1309
Mailing Address - Country:US
Mailing Address - Phone:323-755-9694
Mailing Address - Fax:323-755-9694
Practice Address - Street 1:2010 E EL SEGUNDO BLVD
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90222-7109
Practice Address - Country:US
Practice Address - Phone:310-637-0917
Practice Address - Fax:310-637-0473
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner