Provider Demographics
NPI:1912114232
Name:RUNCO, LODIA A (OT)
Entity Type:Individual
Prefix:
First Name:LODIA
Middle Name:A
Last Name:RUNCO
Suffix:
Gender:F
Credentials:OT
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 523
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49429-0523
Mailing Address - Country:US
Mailing Address - Phone:616-457-4919
Mailing Address - Fax:616-457-5261
Practice Address - Street 1:29829 TELEGRAPH RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1330
Practice Address - Country:US
Practice Address - Phone:248-352-4263
Practice Address - Fax:248-352-2915
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201001703225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN87170001Medicare ID - Type UnspecifiedMEDICARE