1639371008 NPI number — RUSSELL PEN GAINES LMT

Table of content: RUSSELL PEN GAINES LMT (NPI 1639371008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639371008 NPI number — RUSSELL PEN GAINES LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GAINES
Provider First Name:
RUSSELL
Provider Middle Name:
PEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GAINES
Provider Other First Name:
RUSS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MASSAGE THERAPY
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1639371008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 DORAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHALIMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-651-1732
Provider Business Mailing Address Fax Number:
850-651-1732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3999 COMMONS DR W
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
DESTIN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-837-9552
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2007

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: 225700000X , with the licence number:  MA18637 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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