MEDICARE: RICHARD N KITTELSON

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	332H00000X	Eyewear Supplier		MN
2	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
2	2100679	OTHER	MN	MEDICA
3	OPT301766	OTHER	ND	NORTH DAKOTA VISION SERVI

General Provider Information

NPI Number	:	1962496570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RICHARD N KITTELSON

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	:	OPTICIAN/OWNER
Name	:	MR. RICHARD N KITTELSON
Credential	:	ABOC
Telephone Number	:	218-847-8021

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	09/11/2025

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