Provider Demographics
NPI:1083090765
Name:KLETTENBERG, LOGAN (DC)
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:KLETTENBERG
Suffix:
Gender:M
Credentials:DC
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 872
Mailing Address - Street 2:
Mailing Address - City:BAGLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56621-0872
Mailing Address - Country:US
Mailing Address - Phone:186-942-2422
Mailing Address - Fax:
Practice Address - Street 1:119 MAIN AVE N
Practice Address - Street 2:
Practice Address - City:BAGLEY
Practice Address - State:MN
Practice Address - Zip Code:56621-8316
Practice Address - Country:US
Practice Address - Phone:218-252-9455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6119111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor