Provider Demographics
NPI:1578636908
Name:KNOELL, CLINTON EUGENE (HAD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:EUGENE
Last Name:KNOELL
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 S 16TH ST
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-7569
Mailing Address - Country:US
Mailing Address - Phone:712-623-2565
Mailing Address - Fax:
Practice Address - Street 1:411 E REED ST
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:IA
Practice Address - Zip Code:51566-2372
Practice Address - Country:US
Practice Address - Phone:712-623-2565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00862237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0463398Medicaid