Provider Demographics
NPI:1760048078
Name:LUNDE, KEVIN CARLYLE X
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CARLYLE
Last Name:LUNDE
Suffix:X
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 MERRYWOOD CT
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-6529
Mailing Address - Country:US
Mailing Address - Phone:507-491-2900
Mailing Address - Fax:
Practice Address - Street 1:1321 MERRYWOOD CT
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6529
Practice Address - Country:US
Practice Address - Phone:507-491-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1093031-1-AFCOtherDEPARTMENT OF HUMAN SERVICES
MNRV934ROtherPROVIDER