Provider Demographics
NPI:1780180497
Name:RUNDE, JOHN LUCAS
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LUCAS
Last Name:RUNDE
Suffix:
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 1:8861 GILMORE LAKE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:IL
Mailing Address - Zip Code:62236-3525
Mailing Address - Country:US
Mailing Address - Phone:217-663-4090
Mailing Address - Fax:
Practice Address - Street 1:5201 MID AMERICA PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-0002
Practice Address - Country:US
Practice Address - Phone:217-663-4090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-02
Last Update Date:2018-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20150360022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty