Basic Information
| Provider Information | |||||||||
| NPI: | 1578988218 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLISLE | ||||||||
| FirstName: | RUSSELL | ||||||||
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| Credential: | ATC, LAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 123 WILLOW CT | ||||||||
| Address2: | |||||||||
| City: | RACELAND | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703942732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9856880478 | ||||||||
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| Practice Location | |||||||||
| Address1: | 602 N ACADIA RD | ||||||||
| Address2: | |||||||||
| City: | THIBODAUX | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703014847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9854475500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2014 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | ATH.200033 | LA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.