Provider Demographics
NPI:1578012886
Name:RUNKLE, LANDON
Entity Type:Individual
Prefix:
First Name:LANDON
Middle Name:
Last Name:RUNKLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 S CHICAGO ST APT 8
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:IL
Mailing Address - Zip Code:60953-1286
Mailing Address - Country:US
Mailing Address - Phone:779-212-2762
Mailing Address - Fax:
Practice Address - Street 1:221 S CHICAGO ST APT 8
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:IL
Practice Address - Zip Code:60953-1286
Practice Address - Country:US
Practice Address - Phone:779-212-2762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer