Healthcare Provider Details

I. General information

NPI: 1548989502
Provider Name (Legal Business Name): KCPEDSRD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 SW WINTERFIELD CT
LEES SUMMIT MO
64081-4098
US

IV. Provider business mailing address

8450 NW PRAIRIE VIEW RD # 1441
KANSAS CITY MO
64153-1841
US

V. Phone/Fax

Practice location:
  • Phone: 816-875-0077
  • Fax:
Mailing address:
  • Phone: 816-875-0077
  • Fax: 507-322-1832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. ALEXANDRA MAE GREGG
Title or Position: DIETITIAN
Credential: RD, LD
Phone: 816-875-0077