Healthcare Provider Details

I. General information

NPI: 1033035050
Provider Name (Legal Business Name): MR. RUSSELL C WATERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1737 W 60TH ST # 2
LOS ANGELES CA
90047-1112
US

IV. Provider business mailing address

1737 W 60TH ST # 2
LOS ANGELES CA
90047-1112
US

V. Phone/Fax

Practice location:
  • Phone: 562-536-7397
  • Fax:
Mailing address:
  • Phone: 562-536-7397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: