Provider Demographics
NPI:1811924772
Name:BECHTHOLD, KAYLA MILLER (OD)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:MILLER
Last Name:BECHTHOLD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 1ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:CHISHOLM
Mailing Address - State:MN
Mailing Address - Zip Code:55719-1811
Mailing Address - Country:US
Mailing Address - Phone:218-254-4393
Mailing Address - Fax:218-786-9375
Practice Address - Street 1:11 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:CHISHOLM
Practice Address - State:MN
Practice Address - Zip Code:55719
Practice Address - Country:US
Practice Address - Phone:218-254-4393
Practice Address - Fax:218-786-9375
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN714754600Medicaid