1750753182 NPI number — ZACHARY RUSSELL ATC, LAT, CSCS, OTC

Table of content: ZACHARY RUSSELL ATC, LAT, CSCS, OTC (NPI 1750753182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750753182 NPI number — ZACHARY RUSSELL ATC, LAT, CSCS, OTC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
ZACHARY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC, LAT, CSCS, OTC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750753182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5883 N NEVADA AVE
Provider Second Line Business Mailing Address:
324
Provider Business Mailing Address City Name:
COLORADO SPRINGS
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80918-3507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-481-6519
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1305 JENNINGS MILL ROAD
Provider Second Line Business Practice Location Address:
BUILDING 300, SUITE 110
Provider Business Practice Location Address City Name:
WATKINSVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30677
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-613-5880
Provider Business Practice Location Address Fax Number:
706-613-5880
Provider Enumeration Date:
10/26/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X , with the licence number:  0001416 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207XX0005X , with the licence number: AT003715 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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