Provider Demographics
NPI:1043499403
Name:RUNYON SPECIFIC CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:RUNYON SPECIFIC CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:RUNYON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:606-833-9355
Mailing Address - Street 1:PO BOX 741
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0741
Mailing Address - Country:US
Mailing Address - Phone:606-833-9355
Mailing Address - Fax:606-833-1895
Practice Address - Street 1:1448 DIEDERICH BLVD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:KY
Practice Address - Zip Code:41169-1719
Practice Address - Country:US
Practice Address - Phone:606-833-9355
Practice Address - Fax:606-833-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4816111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85003416Medicaid
KY000000336562OtherBLUE CROSS BLUE SHIELD
OH2634242Medicaid
KY000000336562OtherBLUE CROSS BLUE SHIELD