Provider Demographics
NPI:1003237736
Name:KITTELSON, BRAD (LRD)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:KITTELSON
Suffix:
Gender:M
Credentials:LRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58107-2168
Mailing Address - Country:US
Mailing Address - Phone:701-234-2119
Mailing Address - Fax:
Practice Address - Street 1:1720 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-280-4474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-24
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND397133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND56318Medicaid
NDN719446Medicare PIN
NDN719447Medicare PIN