Healthcare Provider Details

I. General information

NPI: 1508306010
Provider Name (Legal Business Name): RUSSELL PIAZZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 RICARDO COURT
SAN LUIS OBISPO CA
93401
US

IV. Provider business mailing address

873 RICARDO CT
SAN LUIS OBISPO CA
93401-7174
US

V. Phone/Fax

Practice location:
  • Phone: 805-784-0515
  • Fax:
Mailing address:
  • Phone: 805-784-0515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number26644
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: