Healthcare Provider Details

I. General information

NPI: 1518254853
Provider Name (Legal Business Name): RUSSELL DEE CASH BOARD CERTIFIED
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6876 FAIRVIEW AVE
BOISE ID
83704-8501
US

IV. Provider business mailing address

6876 FAIRVIEW AVE
BOISE ID
83704-8501
US

V. Phone/Fax

Practice location:
  • Phone: 208-376-9431
  • Fax: 208-378-0747
Mailing address:
  • Phone: 208-376-9431
  • Fax: 208-378-0747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA-181
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: