Provider Demographics
NPI:1770739369
Name:WKRP HOUSTON LLC
Entity type:Organization
Organization Name:WKRP HOUSTON LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:RADCLIFFE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:281-530-7829
Mailing Address - Street 1:7058 LAKEVIEW HAVEN DRIVE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77095
Mailing Address - Country:US
Mailing Address - Phone:281-530-7829
Mailing Address - Fax:281-598-2897
Practice Address - Street 1:7058 LAKEVIEW HAVEN DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77095
Practice Address - Country:US
Practice Address - Phone:281-530-7829
Practice Address - Fax:281-598-2897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251G00000X
TX012218251G00000X
TX16111251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001019519Medicaid
TX67-1617Medicare PIN
TX67-167Medicare PIN