Healthcare Provider Details

I. General information

NPI: 1962496570
Provider Name (Legal Business Name): RICHARD N KITTELSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 WASHINGTON AVE
DETROIT LAKES MN
56501-3402
US

IV. Provider business mailing address

918 WASHINGTON AVE
DETROIT LAKES MN
56501-3402
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-8021
  • Fax: 218-846-9552
Mailing address:
  • Phone: 218-847-8021
  • Fax: 218-846-9552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number03590
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateMN

VIII. Authorized Official

Name: MR. RICHARD N KITTELSON
Title or Position: OPTICIAN/OWNER
Credential: ABOC
Phone: 218-847-8021