Healthcare Provider Details

I. General information

NPI: 1134196751
Provider Name (Legal Business Name): KENNAN THOMAS RUNTE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MARGARET LANE STE B-1
GRASS VALLEY CA
95945
US

IV. Provider business mailing address

123 MARGARET LANE STE B-1
GRASS VALLEY CA
95945
US

V. Phone/Fax

Practice location:
  • Phone: 530-477-7200
  • Fax: 530-477-1246
Mailing address:
  • Phone: 530-477-7200
  • Fax: 530-477-1246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE37870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: