Healthcare Provider Details

I. General information

NPI: 1639010101
Provider Name (Legal Business Name): RUSSELL JAY NILAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 CAMINO DEL RIO SOUTH SUITE 300
SAN DIEGO CA
92108
US

IV. Provider business mailing address

1011 CAMINO DEL RIO SOUTH SUITE 300
SAN DIEGO CA
92108
US

V. Phone/Fax

Practice location:
  • Phone: 619-287-8225
  • Fax: 619-393-0386
Mailing address:
  • Phone: 619-287-8225
  • Fax: 619-393-0386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-WMGELR
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: