Provider Demographics
NPI:1164259552
Name:RUSSO, FRANK T (PT, DPT)
Entity type:Individual
Prefix:
First Name:FRANK
Middle Name:T
Last Name:RUSSO
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 VILLAGE CENTER BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6706
Mailing Address - Country:US
Mailing Address - Phone:843-353-3460
Mailing Address - Fax:843-353-3461
Practice Address - Street 1:1621 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2229
Practice Address - Country:US
Practice Address - Phone:843-353-3460
Practice Address - Fax:843-353-3461
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12580225100000X
NY052834225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty