Provider Demographics
NPI:1407000607
Name:RUNNIN WJ THERAPEUTIC CENTER INC
Entity Type:Organization
Organization Name:RUNNIN WJ THERAPEUTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-838-3223
Mailing Address - Street 1:4802 S KINGS HWY
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-8664
Mailing Address - Country:US
Mailing Address - Phone:903-838-3223
Mailing Address - Fax:
Practice Address - Street 1:4802 S KINGS HWY
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-8664
Practice Address - Country:US
Practice Address - Phone:903-838-3223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty