Provider Demographics
NPI:1184684532
Name:RUNNER, CALVIN DEAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:CALVIN
Middle Name:DEAN
Last Name:RUNNER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N ANKENY BLVD SUITE 200
Mailing Address - Street 2:ANKENY PHYSICAL SPORTS THERAPY
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50021
Mailing Address - Country:US
Mailing Address - Phone:515-965-1422
Mailing Address - Fax:515-965-1449
Practice Address - Street 1:301 N ANKENY BLVD SUITE 200
Practice Address - Street 2:ANKENY PHYSICAL SPORTS THERAPY
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021
Practice Address - Country:US
Practice Address - Phone:515-965-1422
Practice Address - Fax:515-965-1449
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00651225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0166547Medicaid
IA166547Medicare ID - Type Unspecified