Basic Information
| Provider Information | |||||||||
| NPI: | 1013264530 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUSSELL | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6169 S JOG RD | ||||||||
| Address2: | SUITE A11 | ||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334676579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614320111 | ||||||||
| FaxNumber: | 5614321075 | ||||||||
| Practice Location | |||||||||
| Address1: | 11482 OKEECHOBEE BLVD | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ROYAL PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334118735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614320111 | ||||||||
| FaxNumber: | 5614321075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2012 | ||||||||
| LastUpdateDate: | 05/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT27587 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.