Provider Demographics
NPI:1841423480
Name:BLAIN, RUSSELL FRANKLIN (LMP)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:FRANKLIN
Last Name:BLAIN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 SELAH LOOP RD TRLR 79
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-9473
Mailing Address - Country:US
Mailing Address - Phone:509-480-2106
Mailing Address - Fax:
Practice Address - Street 1:2812 TERRACE HEIGHTS DR STE 8
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-1439
Practice Address - Country:US
Practice Address - Phone:509-480-2106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-31
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00024842225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist