Provider Demographics
NPI:1790413524
Name:SETSUDA, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:SETSUDA
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 1:1647 N LAVE AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104
Mailing Address - Country:US
Mailing Address - Phone:626-644-4288
Mailing Address - Fax:
Practice Address - Street 1:1647 N LAVE AVE
Practice Address - Street 2:APT 2
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104
Practice Address - Country:US
Practice Address - Phone:626-644-4288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39280225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1CD0KA7KD43Medicaid