Basic Information
| Provider Information | |||||||||
| NPI: | 1205044161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KJORLEIN | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | ELISA | ||||||||
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| OtherLastName: | COSTANZO | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | ELISA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 49 | ||||||||
| Address2: | |||||||||
| City: | CLEAR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55319 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2450 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126726000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225000000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter |
No ID Information.