Healthcare Provider Details

I. General information

NPI: 1487895116
Provider Name (Legal Business Name): MICHAEL CLARENCE RUSS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6621 CA-1 SUITE 120
LONG BEACH CA
90803
US

IV. Provider business mailing address

18672 APPLEWOOD CIR # 75
HUNTINGTON BEACH CA
92646-1861
US

V. Phone/Fax

Practice location:
  • Phone: 716-341-5152
  • Fax:
Mailing address:
  • Phone: 716-341-5152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number022275
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: