Healthcare Provider Details

I. General information

NPI: 1184684532
Provider Name (Legal Business Name): CALVIN DEAN RUNNER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N ANKENY BLVD SUITE 200 ANKENY PHYSICAL SPORTS THERAPY
ANKENY IA
50021
US

IV. Provider business mailing address

301 N ANKENY BLVD SUITE 200 ANKENY PHYSICAL SPORTS THERAPY
ANKENY IA
50021
US

V. Phone/Fax

Practice location:
  • Phone: 515-965-1422
  • Fax: 515-965-1449
Mailing address:
  • Phone: 515-965-1422
  • Fax: 515-965-1449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number00651
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: