Healthcare Provider Details

I. General information

NPI: 1063682698
Provider Name (Legal Business Name): KAREEM RUSSELL CST/CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 E DESERT INN RD STE 100
LAS VEGAS NV
89121-3609
US

IV. Provider business mailing address

5023 SILHOUETTE AVE
LAS VEGAS NV
89142-1770
US

V. Phone/Fax

Practice location:
  • Phone: 702-294-7402
  • Fax: 702-735-7966
Mailing address:
  • Phone: 702-336-9313
  • Fax: 702-407-0571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number87842
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: