Healthcare Provider Details

I. General information

NPI: 1063685840
Provider Name (Legal Business Name): PHILLIP RUNYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2008
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3399 FINCH RD
BISMARCK AR
71929-7541
US

IV. Provider business mailing address

PO BOX 108
BISMARCK AR
71929-0108
US

V. Phone/Fax

Practice location:
  • Phone: 501-865-3363
  • Fax:
Mailing address:
  • Phone: 501-865-3363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: