Provider Demographics
NPI:1700134046
Name:RUSS RECOVERY IOP SERVCES- PC
Entity Type:Organization
Organization Name:RUSS RECOVERY IOP SERVCES- PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:RUSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-416-7755
Mailing Address - Street 1:2825 TAHQUITZ CANYON WAY
Mailing Address - Street 2:BLDG C
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-7038
Mailing Address - Country:US
Mailing Address - Phone:866-484-6444
Mailing Address - Fax:760-416-7709
Practice Address - Street 1:2825 TAHQUITZ CANYON WAY
Practice Address - Street 2:BLDG C
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262
Practice Address - Country:US
Practice Address - Phone:866-484-6444
Practice Address - Fax:760-416-7709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAMFC49984261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)Group - Multi-Specialty