Provider Demographics
NPI:1962487066
Name:KOSKOVICH, CAROL (RD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:KOSKOVICH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MEDICAL CENTER DR
Mailing Address - Street 2:PO BOX 800
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4575
Mailing Address - Country:US
Mailing Address - Phone:507-238-8555
Mailing Address - Fax:
Practice Address - Street 1:800 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4575
Practice Address - Country:US
Practice Address - Phone:507-238-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1662133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN63-00305OtherMEDICA