1952591968 NPI number — TIMOTHY D RUNNELS

Table of content: (NPI 1952591968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952591968 NPI number — TIMOTHY D RUNNELS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIMOTHY D RUNNELS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952591968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5643 TREASCHWIG RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77373-7162
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-443-1287
Provider Business Mailing Address Fax Number:
281-443-1288

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5643 TREASCHWIG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77373-7162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-443-1287
Provider Business Practice Location Address Fax Number:
281-443-1288
Provider Enumeration Date:
07/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RUNNELS
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
281-443-1287

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  9478 , 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)

  • Identifier: 608370 . This is a "BLUE CROSS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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