Healthcare Provider Details

I. General information

NPI: 1881550085
Provider Name (Legal Business Name): ROBERT GEORGE KUNKLE III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/31/2025
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 SW SCALEHOUSE CT STE 130
BEND OR
97702-3241
US

IV. Provider business mailing address

532 NW GREYHAWK AVE
BEND OR
97703-5607
US

V. Phone/Fax

Practice location:
  • Phone: 541-923-2654
  • Fax:
Mailing address:
  • Phone: 541-923-2654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: