Provider Demographics
NPI:1801405113
Name:RUSSELL, TERRY
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4285 N RANCHO DR STE 160
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-3456
Mailing Address - Country:US
Mailing Address - Phone:702-835-1911
Mailing Address - Fax:702-851-8528
Practice Address - Street 1:4285 N RANCHO DR STE 160
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89130-3456
Practice Address - Country:US
Practice Address - Phone:702-835-1911
Practice Address - Fax:702-851-8528
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner