MEDICARE: MICHAEL ROCKY RUSSO

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	171400000X	Health & Wellness Coach		CA

General Provider Information

NPI Number	:	1548195431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL ROCKY RUSSO

Provider Business Mailing Address
First Line	:	17982 LUCERO WAY
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-2624
Country	:	US
Telephone Number	:	808-987-1151
Fax Number	:

Provider Business Practice Location Address
First Line	:	17982 LUCERO WAY
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92780-2624
Country	:	US
Telephone Number	:	808-987-1151
Fax Number	:

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

Provider Enumeration Date	:	06/15/2026
Last Update Date	:	06/15/2026

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