Provider Demographics
NPI:1164849212
Name:RUSSELL, DARREN
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:542 ARBOR CT
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-8238
Mailing Address - Country:US
Mailing Address - Phone:818-807-4206
Mailing Address - Fax:
Practice Address - Street 1:542 ARBOR CT
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-8238
Practice Address - Country:US
Practice Address - Phone:818-807-4206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program