MEDICARE: GLEN RUSSEL ARN LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00023548	WA

General Provider Information

NPI Number	:	1033443007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN RUSSEL ARN LMP

Provider Business Mailing Address
First Line	:	1913 NW 7TH CT
Second Line	:
City	:	BATTLE GROUND
State	:	WA
Zip	:	98604-6805
Country	:	US
Telephone Number	:	360-521-0804
Fax Number	:

Provider Business Practice Location Address
First Line	:	2402 BROADWAY ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98663-3229
Country	:	US
Telephone Number	:	360-521-0804
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2009
Last Update Date	:	09/24/2009

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