Provider Demographics
NPI:1073287983
Name:RUNCIK, CAROL ANN (LMT)
Entity Type:Individual
Prefix:
First Name:CAROL ANN
Middle Name:
Last Name:RUNCIK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 12TH ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-2618
Mailing Address - Country:US
Mailing Address - Phone:605-342-3908
Mailing Address - Fax:605-716-0645
Practice Address - Street 1:350 12TH ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2618
Practice Address - Country:US
Practice Address - Phone:605-342-3908
Practice Address - Fax:605-716-0645
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT10152225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist