Provider Demographics
NPI:1891235552
Name:FREESTONE, RUSSELL W (LMT)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:W
Last Name:FREESTONE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 W WINCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7069
Mailing Address - Country:US
Mailing Address - Phone:208-378-1377
Mailing Address - Fax:
Practice Address - Street 1:8700 W WINCHESTER DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7069
Practice Address - Country:US
Practice Address - Phone:208-378-1377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-2217225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist