Provider Demographics
NPI:1629673009
Name:RUSSELL, RYLAN (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:RYLAN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 N 400 E LOWR LEVEL
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2243
Mailing Address - Country:US
Mailing Address - Phone:801-392-1767
Mailing Address - Fax:
Practice Address - Street 1:2602 N. 400 E, LOWER LEVEL #5
Practice Address - Street 2:LOWER LEVEL #5
Practice Address - City:NORTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84414-8441
Practice Address - Country:US
Practice Address - Phone:801-392-1767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist