MEDICARE: MRS. JOELYN MARIE KLONCZ

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	171W00000X	Contractor	1044577-2-AFC	MN

General Provider Information

NPI Number	:	1093856239
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOELYN MARIE KLONCZ

Provider Business Mailing Address
First Line	:	9839 54TH ST
Second Line	:
City	:	CLEAR LAKE
State	:	MN
Zip	:	55319-9556
Country	:	US
Telephone Number	:	320-743-5495
Fax Number	:

Provider Business Practice Location Address
First Line	:	9839 54TH ST
Second Line	:
City	:	CLEAR LAKE
State	:	MN
Zip	:	55319-9556
Country	:	US
Telephone Number	:	320-743-5495
Fax Number	:

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

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	07/08/2007

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