Healthcare Provider Details

I. General information

NPI: 1407114143
Provider Name (Legal Business Name): MR. RUSSELL SANCHEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2012
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 LIMITED LN NW STE B
OLYMPIA WA
98502-2638
US

IV. Provider business mailing address

3015 LIMITED LN NW STE B
OLYMPIA WA
98502-2638
US

V. Phone/Fax

Practice location:
  • Phone: 360-709-0700
  • Fax: 360-709-0703
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number60266820
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number9312
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: