MEDICARE: MR. RUSS KINGMAN DECKER JR. M.S.

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	106H00000X	Marriage & Family Therapist	51257	CA

General Provider Information

NPI Number	:	1932310802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUSS KINGMAN DECKER JR. M.S.

Provider Business Mailing Address
First Line	:	32184 COVE CIRCLE
Second Line	:	P.O. BOX 3254
City	:	RUNNING SPRINGS
State	:	CA
Zip	:	92382
Country	:	US
Telephone Number	:	909-867-4879
Fax Number	:

Provider Business Practice Location Address
First Line	:	32184 COVE CIRCLE
Second Line	:
City	:	RUNNING SPRINGS
State	:	CA
Zip	:	92382
Country	:	US
Telephone Number	:	909-867-4879
Fax Number	:

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

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	07/08/2007

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