Healthcare Provider Details

I. General information

NPI: 1023975737
Provider Name (Legal Business Name): WAYNE CHARLES RUSSI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 12/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 N OAK ST #1967
HILDALE UT
84784-1967
US

IV. Provider business mailing address

525 E WILLIAMS AVE #1967
HILDALE UT
84784-1967
US

V. Phone/Fax

Practice location:
  • Phone: 719-217-1967
  • Fax:
Mailing address:
  • Phone: 719-217-1967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number242714954
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: