Healthcare Provider Details

I. General information

NPI: 1063910842
Provider Name (Legal Business Name): RUNNING WILD SEA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8557 RESEARCH BLVD STE 128
AUSTIN TX
78758-7855
US

IV. Provider business mailing address

PO BOX 10414
AUSTIN TX
78766-1414
US

V. Phone/Fax

Practice location:
  • Phone: 512-836-7399
  • Fax: 512-836-7399
Mailing address:
  • Phone: 512-944-4585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LOANN TRINH
Title or Position: DIRECTOR
Credential: DO
Phone: 512-944-4585