Provider Demographics
NPI:1558337402
Name:LUNDEEN, KENNETH DAVID (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAVID
Last Name:LUNDEEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13128 N 94TH DR STE 207
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4253
Mailing Address - Country:US
Mailing Address - Phone:623-974-1797
Mailing Address - Fax:623-974-1798
Practice Address - Street 1:13128 N 94TH DR STE 207
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4253
Practice Address - Country:US
Practice Address - Phone:623-974-1797
Practice Address - Fax:623-974-1798
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ683225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2Z2293OtherHEALTH NET
AZ74518OtherBLUE CROSS BLUE SHIELD
AZ860744695OtherUNITED HEALTHCARE
AZ650010309OtherRAILROAD MEDICARE
AZ719065OtherAHCCCS
AZ2Z2293OtherHEALTH NET