Provider Demographics
NPI:1972796175
Name:TOLLIVER, RUSSELL WAYNE
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:WAYNE
Last Name:TOLLIVER
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 1:4083 SUNBEAM RD
Mailing Address - Street 2:APARTMENT 1409
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-8993
Mailing Address - Country:US
Mailing Address - Phone:904-733-1338
Mailing Address - Fax:
Practice Address - Street 1:4083 SUNBEAM RD
Practice Address - Street 2:APARTMENT 1409
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-8993
Practice Address - Country:US
Practice Address - Phone:904-733-1338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility