Healthcare Provider Details

I. General information

NPI: 1780180497
Provider Name (Legal Business Name): JOHN LUCAS RUNDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 04/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 MID AMERICA PLZ
SAINT LOUIS MO
63129-0002
US

IV. Provider business mailing address

8861 GILMORE LAKE RD
COLUMBIA IL
62236-3525
US

V. Phone/Fax

Practice location:
  • Phone: 217-663-4090
  • Fax:
Mailing address:
  • Phone: 217-663-4090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2015036002
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: