Healthcare Provider Details

I. General information

NPI: 1598237893
Provider Name (Legal Business Name): JOHN RUSSELL HUTTON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2018
Last Update Date: 12/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 S MILLSTREAM CT
NAMPA ID
83686-4838
US

IV. Provider business mailing address

1461 S MILLSTREAM CT
NAMPA ID
83686-4838
US

V. Phone/Fax

Practice location:
  • Phone: 209-604-8993
  • Fax:
Mailing address:
  • Phone: 209-604-8993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1948
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: