Provider Demographics
NPI:1366547036
Name:ALMENDAREZ, RUSSELL NATHAN SR (PT A)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:NATHAN
Last Name:ALMENDAREZ
Suffix:SR
Gender:M
Credentials:PT A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34283 VIA BUENA DRIVE
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2520
Mailing Address - Country:US
Mailing Address - Phone:909-790-2039
Mailing Address - Fax:
Practice Address - Street 1:11201 BENTON STREET
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 6636174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist