Healthcare Provider Details

I. General information

NPI: 1497184352
Provider Name (Legal Business Name): JILL RUBY RUNAS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2013
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23517 MAIN ST STE 103
CARSON CA
90745-5234
US

IV. Provider business mailing address

26051 FRAMPTON AVENUE
HARBOR CITY CA
90710
US

V. Phone/Fax

Practice location:
  • Phone: 310-834-5388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number710801
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number22997
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: