=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336239888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RANDY ROY LUNDELL D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 09/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 954 N 200 E STE 954
-----------------------------------------------------
City | SPANISH FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84660-1247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-504-6117
-----------------------------------------------------
Fax | 801-504-6328
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 468 S MAIN ST
-----------------------------------------------------
City | SPANISH FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84660-2410
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-504-6117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5807043-1204
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------