Provider Demographics
NPI:1477852580
Name:SMITH, RUSSELL DALE (LMT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:DALE
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6620 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-3160
Mailing Address - Country:US
Mailing Address - Phone:503-812-4435
Mailing Address - Fax:
Practice Address - Street 1:309 ELM AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3437
Practice Address - Country:US
Practice Address - Phone:503-812-4435
Practice Address - Fax:503-842-0396
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2012-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15176225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist