MEDICARE: RICHARD NEAL KITTELSON ABOC

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	156FX1800X	Optician	03590	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1C991OP	OTHER	MN	BLUE CROSS BLUE SHIELD OF MINNESOTA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2100679	OTHER	MN	MEDICA

General Provider Information

NPI Number	:	1790942332
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD NEAL KITTELSON ABOC

Provider Business Mailing Address
First Line	:	918 WASHINGTON AVE
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3402
Country	:	US
Telephone Number	:	218-847-8021
Fax Number	:	218-846-9552

Provider Business Practice Location Address
First Line	:	918 WASHINGTON AVE
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3402
Country	:	US
Telephone Number	:	218-847-8021
Fax Number	:	218-846-9552

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

Provider Enumeration Date	:	05/21/2008
Last Update Date	:	03/07/2012

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