Healthcare Provider Details

I. General information

NPI: 1962487066
Provider Name (Legal Business Name): CAROL KOSKOVICH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 MEDICAL CENTER DR
FAIRMONT MN
56031-4575
US

IV. Provider business mailing address

800 MEDICAL CENTER DR PO BOX 800
FAIRMONT MN
56031-4575
US

V. Phone/Fax

Practice location:
  • Phone: 507-238-8555
  • Fax:
Mailing address:
  • Phone: 507-238-8555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1662
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: