Provider Demographics
NPI:1376105031
Name:RUNYAN, VICTORIA EILEEN
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:EILEEN
Last Name:RUNYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 301
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91012-0301
Mailing Address - Country:US
Mailing Address - Phone:747-218-3173
Mailing Address - Fax:
Practice Address - Street 1:10605 EMPIRE DR
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-2040
Practice Address - Country:US
Practice Address - Phone:747-218-3173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68571225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist