MEDICARE: DR. ETHAN JOHN KLECKNER D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	06264	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09304	OTHER	IA	BLUE CROSS NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710072848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETHAN JOHN KLECKNER D.C.

Provider Business Mailing Address
First Line	:	250 W 1ST ST
Second Line	:	STE C
City	:	GRIMES
State	:	IA
Zip	:	50111-2138
Country	:	US
Telephone Number	:	515-986-2233
Fax Number	:	515-986-0041

Provider Business Practice Location Address
First Line	:	250 SW 1ST STREET
Second Line	:	STE C
City	:	GRIMES
State	:	IA
Zip	:	50111-2138
Country	:	US
Telephone Number	:	515-986-2233
Fax Number	:	515-986-0041

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	10/13/2010

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