1104877760 NPI number — RANDALL K CUNDIFF ARNP

Table of content: RANDALL K CUNDIFF ARNP (NPI 1104877760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104877760 NPI number — RANDALL K CUNDIFF ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUNDIFF
Provider First Name:
RANDALL
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104877760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 803929
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KANSAS CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64180-3929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-953-0104
Provider Business Mailing Address Fax Number:
303-765-6670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
311 E SPRUCE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67846-5614
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-275-3030
Provider Business Practice Location Address Fax Number:
620-275-3025
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  44884 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100338290C , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".




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