Provider Demographics
NPI:1710072848
Name:KLECKNER, ETHAN JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:JOHN
Last Name:KLECKNER
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 1:250 W 1ST ST
Mailing Address - Street 2:STE C
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-2138
Mailing Address - Country:US
Mailing Address - Phone:515-986-2233
Mailing Address - Fax:515-986-0041
Practice Address - Street 1:250 SW 1ST STREET
Practice Address - Street 2:STE C
Practice Address - City:GRIMES
Practice Address - State:IA
Practice Address - Zip Code:50111-2138
Practice Address - Country:US
Practice Address - Phone:515-986-2233
Practice Address - Fax:515-986-0041
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06264111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA09304OtherBLUE CROSS NUMBER
IA0205567Medicaid
IA09304OtherBLUE CROSS NUMBER
IA09304Medicare PIN