Provider Demographics
NPI:1821268855
Name:RUSS REYNOLDS
Entity Type:Organization
Organization Name:RUSS REYNOLDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSS
Authorized Official - Middle Name:K
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:509-884-0602
Mailing Address - Street 1:220 25TH ST NE
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-4097
Mailing Address - Country:US
Mailing Address - Phone:509-884-0602
Mailing Address - Fax:509-884-0602
Practice Address - Street 1:220 25TH ST NE
Practice Address - Street 2:
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-4097
Practice Address - Country:US
Practice Address - Phone:509-884-0602
Practice Address - Fax:509-884-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WART00003044335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7015290Medicaid
WAG000315368Medicare UPIN
WA7015290Medicaid