MEDICARE: DARREN RUSSELL

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1164849212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARREN RUSSELL

Provider Business Mailing Address
First Line	:	542 ARBOR CT
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-8238
Country	:	US
Telephone Number	:	818-807-4206
Fax Number	:

Provider Business Practice Location Address
First Line	:	542 ARBOR CT
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-8238
Country	:	US
Telephone Number	:	818-807-4206
Fax Number	:

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

Provider Enumeration Date	:	03/26/2014
Last Update Date	:	03/26/2014

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Directions to “ DARREN RUSSELL ” Practice Location

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