Provider Demographics
NPI:1568456671
Name:RUNCO, PHILLIP J (DC)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:J
Last Name:RUNCO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 TREAT BLVD
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-3601
Mailing Address - Country:US
Mailing Address - Phone:925-685-0335
Mailing Address - Fax:925-685-8883
Practice Address - Street 1:2975 TREAT BLVD
Practice Address - Street 2:SUITE A-2
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-3601
Practice Address - Country:US
Practice Address - Phone:925-685-0335
Practice Address - Fax:925-685-8883
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2008-10-09
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
CA16845111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0168450Medicare UPIN
CADC0168450Medicare ID - Type Unspecified