Healthcare Provider Details

I. General information

NPI: 1093807687
Provider Name (Legal Business Name): KENNETH OMUNDSON RPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 FERN ST N
CAMBRIDGE MN
55008-1033
US

IV. Provider business mailing address

11139 264TH ST
SAINT CLOUD MN
56301-9411
US

V. Phone/Fax

Practice location:
  • Phone: 763-689-5385
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2319
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: