Provider Demographics
NPI:1639371008
Name:GAINES, RUSSELL PEN (LMT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:PEN
Last Name:GAINES
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:RUSS
Other - Middle Name:
Other - Last Name:GAINES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASSAGE THERAPY
Mailing Address - Street 1:17 DORAL DR
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579
Mailing Address - Country:US
Mailing Address - Phone:850-651-1732
Mailing Address - Fax:850-651-1732
Practice Address - Street 1:3999 COMMONS DR W
Practice Address - Street 2:STE C
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541
Practice Address - Country:US
Practice Address - Phone:850-837-9552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA18637225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist