Provider Demographics
NPI:1962496570
Name:RICHARD N KITTELSON
Entity Type:Organization
Organization Name:RICHARD N KITTELSON
Other - Org Name:OPTICAL EYEDEAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:N
Authorized Official - Last Name:KITTELSON
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:218-847-8021
Mailing Address - Street 1:918 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3402
Mailing Address - Country:US
Mailing Address - Phone:218-847-8021
Mailing Address - Fax:218-846-9552
Practice Address - Street 1:918 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3402
Practice Address - Country:US
Practice Address - Phone:218-847-8021
Practice Address - Fax:218-846-9552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN03590156FX1800X
MN332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1C991OPOtherBLUE CROSS BLUE SHIELD
MN2100679OtherMEDICA
NDOPT301766OtherNORTH DAKOTA VISION SERVI
MN1C991OPOtherBLUE CROSS BLUE SHIELD
MNC06240Medicare ID - Type UnspecifiedWISCONSIN PHYSICIANS SERV