Healthcare Provider Details

I. General information

NPI: 1316929458
Provider Name (Legal Business Name): CAROL REID RUNYAN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 11/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N STATE OF FRANKLIN RD STE 5
JOHNSON CITY TN
37604-3645
US

IV. Provider business mailing address

6700 WASHINGTON AVE S
EDEN PRAIRIE MN
55344-3405
US

V. Phone/Fax

Practice location:
  • Phone: 423-928-9285
  • Fax: 423-328-0795
Mailing address:
  • Phone: 800-328-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2201001303
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA0000001097
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number2101001591
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: