Provider Demographics
NPI:1245076017
Name:MITCHELL, KIRK GORDON
Entity type:Individual
Prefix:
First Name:KIRK
Middle Name:GORDON
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1367 180TH AVE
Mailing Address - Street 2:
Mailing Address - City:OGILVIE
Mailing Address - State:MN
Mailing Address - Zip Code:56358-9081
Mailing Address - Country:US
Mailing Address - Phone:320-345-0915
Mailing Address - Fax:
Practice Address - Street 1:1367 180TH AVE
Practice Address - Street 2:
Practice Address - City:OGILVIE
Practice Address - State:MN
Practice Address - Zip Code:56358-9081
Practice Address - Country:US
Practice Address - Phone:320-345-0915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications