Healthcare Provider Details

I. General information

NPI: 1215121629
Provider Name (Legal Business Name): RANDALL KUNZE DPM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2007
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 HAZEL ST
CARTHAGE MO
64836-2829
US

IV. Provider business mailing address

PO BOX 424
CARTHAGE MO
64836-0424
US

V. Phone/Fax

Practice location:
  • Phone: 417-358-8566
  • Fax: 417-358-2428
Mailing address:
  • Phone: 417-358-8566
  • Fax: 417-358-2428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number000634
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number000634
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number000634
License Number StateMO

VIII. Authorized Official

Name: RANDALL KUNZE
Title or Position: OWNER
Credential: DPM
Phone: 417-358-8566