Healthcare Provider Details

I. General information

NPI: 1285360404
Provider Name (Legal Business Name): WELLBODYKC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2022
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 E KANSAS CITY RD
OLATHE KS
66061-7050
US

IV. Provider business mailing address

14375 NW 63RD ST
KANSAS CITY MO
64152-8701
US

V. Phone/Fax

Practice location:
  • Phone: 913-220-5724
  • Fax: 913-222-1907
Mailing address:
  • Phone: 913-220-5724
  • Fax: 913-222-1907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RANDALL GOLDSTEIN
Title or Position: OWNER
Credential: DO
Phone: 913-220-5724