MEDICARE: AMANDA ROSITAS KJOS OTR/L

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	225X00000X	Occupational Therapist	104311	MN

General Provider Information

NPI Number	:	1922417880
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA ROSITAS KJOS OTR/L

Provider Business Mailing Address
First Line	:	3060 FRONTIER WAY S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-8909
Country	:	US
Telephone Number	:	701-232-2340
Fax Number	:	701-232-2340

Provider Business Practice Location Address
First Line	:	310 RED LAKE BLVD STE B
Second Line	:
City	:	THIEF RIVER FALLS
State	:	MN
Zip	:	56701-2133
Country	:	US
Telephone Number	:	218-416-1482
Fax Number	:	218-416-1483

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

Provider Enumeration Date	:	08/05/2014
Last Update Date	:	06/05/2023

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