Individual
RUSSELL D BERRY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LPTA
Contact information
Practice address
1 WICKERSHAM ST, MANGUM, OK 73554-9117
(580) 782-3353
Mailing address
PO BOX 104, GRANITE, OK 73547-0104
(580) 535-4581
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
812
OK
Other
Enumeration date
05/08/2007
Last updated
03/29/2010
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