Healthcare Provider Details

I. General information

NPI: 1679610356
Provider Name (Legal Business Name): RUSS K REYNOLDS RT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 25TH ST NE
EAST WENATCHEE WA
98802-4097
US

IV. Provider business mailing address

220 25TH ST NE
EAST WENATCHEE WA
98802-4097
US

V. Phone/Fax

Practice location:
  • Phone: 509-884-0602
  • Fax: 509-884-0602
Mailing address:
  • Phone: 509-884-0602
  • Fax: 509-884-0602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberRT00003044
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: