Provider Demographics
NPI:1295798676
Name:DIAL, RUSSELL (PT)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:DIAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5905 SEVERIN DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3806
Mailing Address - Country:US
Mailing Address - Phone:619-589-2606
Mailing Address - Fax:619-464-0900
Practice Address - Street 1:1611 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-2212
Practice Address - Country:US
Practice Address - Phone:760-337-1144
Practice Address - Fax:760-337-8259
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT32388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT32388COtherMEDICARE PTAN