Provider Demographics
NPI:1134604127
Name:KJOLHAUG, CHRISTOPHER MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:MICHAEL
Last Name:KJOLHAUG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2970 CALICO DR S UNIT F
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-4505
Mailing Address - Country:US
Mailing Address - Phone:218-280-8833
Mailing Address - Fax:
Practice Address - Street 1:1131 SOUTH MABELLE AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537
Practice Address - Country:US
Practice Address - Phone:218-998-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1134604127Medicaid