Provider Demographics
NPI:1093807687
Name:OMUNDSON, KENNETH (RPT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:OMUNDSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11139 264TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-9411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 FERN ST N
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1033
Practice Address - Country:US
Practice Address - Phone:763-689-5385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2319225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN483T6OMOtherBCBS
MN6404903OtherMEDICA
MNHP49619OtherHEALTH PARTNERS
MN483T6OMOtherBCBS