Healthcare Provider Details

I. General information

NPI: 1043393192
Provider Name (Legal Business Name): BARBARA MAE RUNYAN R.D.L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3015 VETERANS PKWY S
MOULTRIE GA
31788-6705
US

IV. Provider business mailing address

3015 VETERANS PKWY S P.O. BOX 1177
MOULTRIE GA
31788-6705
US

V. Phone/Fax

Practice location:
  • Phone: 229-985-4815
  • Fax: 229-890-1614
Mailing address:
  • Phone: 229-985-4815
  • Fax: 229-890-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number000142
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: