Healthcare Provider Details

I. General information

NPI: 1992683684
Provider Name (Legal Business Name): RUSSELL EWBANK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W MAIN ST
BRAWLEY CA
92227-2244
US

IV. Provider business mailing address

1134 S 8TH ST
EL CENTRO CA
92243-3968
US

V. Phone/Fax

Practice location:
  • Phone: 760-925-3031
  • Fax:
Mailing address:
  • Phone: 619-961-6156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number52121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: