1215077904 NPI number — MRS. MARSHA K RUNNELS PT

Table of content: MRS. MARSHA K RUNNELS PT (NPI 1215077904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215077904 NPI number — MRS. MARSHA K RUNNELS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUNNELS
Provider First Name:
MARSHA
Provider Middle Name:
K
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KELLOGG
Provider Other First Name:
MARSHA
Provider Other Middle Name:
D
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1215077904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36 BASS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTTSBORO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75076-3121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-786-8986
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
321 N HIGHLAND AVE
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
SHERMAN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75092-7378
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-957-0385
Provider Business Practice Location Address Fax Number:
903-957-4006
Provider Enumeration Date:
02/08/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1105799 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)