Healthcare Provider Details

I. General information

NPI: 1194496687
Provider Name (Legal Business Name): BRIAN RUNDLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 AURORA AVE STE 401E
URBANDALE IA
50322-2866
US

IV. Provider business mailing address

1400 34TH AVE SW APT 409
ALTOONA IA
50009-5459
US

V. Phone/Fax

Practice location:
  • Phone: 515-331-0303
  • Fax: 515-331-9086
Mailing address:
  • Phone: 641-777-7174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number108305
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: