Provider Demographics
NPI:1336657519
Name:ROYSE, DUSTIN ROBERT (CSCS)
Entity type:Individual
Prefix:
First Name:DUSTIN
Middle Name:ROBERT
Last Name:ROYSE
Suffix:
Gender:M
Credentials:CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15703 PACIFIC AVE S STE B
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-4675
Practice Address - Country:US
Practice Address - Phone:253-531-4100
Practice Address - Fax:253-531-3795
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA225100000X
OR7248100954246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR7248100954OtherCSCS