Provider Demographics
NPI:1750753182
Name:RUSSELL, ZACHARY (ATC, LAT, CSCS, OTC)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:ATC, LAT, CSCS, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5883 N NEVADA AVE
Mailing Address - Street 2:324
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-3507
Mailing Address - Country:US
Mailing Address - Phone:678-481-6519
Mailing Address - Fax:
Practice Address - Street 1:1305 JENNINGS MILL ROAD
Practice Address - Street 2:BUILDING 300, SUITE 110
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677
Practice Address - Country:US
Practice Address - Phone:706-613-5880
Practice Address - Fax:706-613-5880
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-26
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001416390200000X
GAAT003715207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program