Provider Demographics
NPI:1740540640
Name:CHRISCHILLES, RUSSELL (PTA-BA)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:CHRISCHILLES
Suffix:
Gender:M
Credentials:PTA-BA
Other - Prefix:
Other - First Name:RUSS
Other - Middle Name:
Other - Last Name:CHRISCHILLES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA-BA
Mailing Address - Street 1:503 LAKEVIEW LN
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-7653
Mailing Address - Country:US
Mailing Address - Phone:712-732-1645
Mailing Address - Fax:
Practice Address - Street 1:1525 W 5TH ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-3027
Practice Address - Country:US
Practice Address - Phone:712-213-8674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0618225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant