Provider Demographics
NPI:1851606586
Name:RUSSELL MIKAMI
Entity Type:Organization
Organization Name:RUSSELL MIKAMI
Other - Org Name:LIGHTHOUSE PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKAMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-928-3443
Mailing Address - Street 1:15413 E VALLEYWAY AVE BLDG B-200
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-8554
Mailing Address - Country:US
Mailing Address - Phone:509-928-3443
Mailing Address - Fax:
Practice Address - Street 1:15413 E VALLEYWAY AVE BLDG B-200
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8554
Practice Address - Country:US
Practice Address - Phone:509-928-3443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-18
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT 00003614174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7107527Medicaid
WA7107527Medicaid