Healthcare Provider Details

I. General information

NPI: 1205659794
Provider Name (Legal Business Name): RUSSEL GUICO GOZAR RPTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MARIANAS HEALTH BUILDING LLC SUITE 102 GHIYEGHI ST. SAN JOSE
SAIPAN MP
96950-8903
US

IV. Provider business mailing address

POB 10003 PMB 1341
SAIPAN MP
96950
US

V. Phone/Fax

Practice location:
  • Phone: 670-233-4646
  • Fax: 670-233-4648
Mailing address:
  • Phone: 670-233-4646
  • Fax: 670-233-4648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06006827A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number002
License Number StateMP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: