Active NPI
Richard Neal Kittelson, ABOC
- Optician
- Detroit Lakes, MN
National Provider Identifier
1790942332
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Optician
- License
- 03590
- Practice address
- 918 Washington Ave
Detroit Lakes, MN 56501-3402 - Phone
- (218) 847-8021
- Fax
- (218) 846-9552
- NPI assigned
- May 21, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Optician | 156FX1800X | 03590 | MN | Primary |
Addresses
Primary practice location
918 Washington Ave
Detroit Lakes, MN 56501-3402
Mailing address
918 Washington Ave
Detroit Lakes, MN 56501-3402
Phone (218) 847-8021
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1C991OP | Other | MN | BLUE CROSS BLUE SHIELD OF MINNESOTA |
| 498762400 | Medicaid | MN | |
| 2100679 | Other | MN | MEDICA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 03590 | MN | MD | Optician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1211328000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1331078400000",
"number": "1790942332",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "918 WASHINGTON AVE",
"city": "DETROIT LAKES",
"state": "MN",
"postal_code": "565013402",
"telephone_number": "218-847-8021",
"fax_number": "218-846-9552"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "918 WASHINGTON AVE",
"city": "DETROIT LAKES",
"state": "MN",
"postal_code": "565013402",
"telephone_number": "218-847-8021",
"fax_number": "218-846-9552"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KITTELSON",
"first_name": "RICHARD",
"middle_name": "NEAL",
"credential": "ABOC",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2008-05-21",
"last_updated": "2012-03-07",
"status": "A"
},
"taxonomies": [
{
"code": "156FX1800X",
"taxonomy_group": "",
"desc": "Technician/Technologist, Optician",
"state": "MN",
"license": "03590",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "BLUE CROSS BLUE SHIELD OF MINNESOTA",
"identifier": "1C991OP",
"state": "MN"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "498762400",
"state": "MN"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MEDICA",
"identifier": "2100679",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Detroit Lakes, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.