Provider Demographics
NPI:1962183178
Name:RUNSTROM, CHARLES ROBERT
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:ROBERT
Last Name:RUNSTROM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 OLD FAYETTEVILLE RD APT C304
Mailing Address - Street 2:
Mailing Address - City:CARRBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27510-5506
Mailing Address - Country:US
Mailing Address - Phone:231-878-0305
Mailing Address - Fax:
Practice Address - Street 1:320 EMERGENCY ROOM DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-5035
Practice Address - Country:US
Practice Address - Phone:919-966-2281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-56162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer