Individual
BRYAN RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
32300 S 625 RD, GROVE, OK 74344-6285
(918) 786-2930
(918) 786-5985
Mailing address
PO BOX 451585, GROVE, OK 74345-1585
(918) 786-2930
(918) 786-5985
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
—
—
Other
Enumeration date
02/14/2017
Last updated
02/14/2017
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