Provider Demographics
NPI:1396918884
Name:JOHN KLOSTER
Entity type:Organization
Organization Name:JOHN KLOSTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN KLOSTER
Authorized Official - Middle Name:NELS
Authorized Official - Last Name:KLOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:O,D,
Authorized Official - Phone:218-568-5555
Mailing Address - Street 1:PO BOX 176
Mailing Address - Street 2:
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472-0176
Mailing Address - Country:US
Mailing Address - Phone:218-568-5555
Mailing Address - Fax:218-568-8904
Practice Address - Street 1:4461 MAIN ST,
Practice Address - Street 2:
Practice Address - City:PEQUOT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56472
Practice Address - Country:US
Practice Address - Phone:218-568-5555
Practice Address - Fax:218-568-8904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2316152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN64756PEOtherBLUE CROSS/ BLUE SHIELD
MN2220699OtherMEDICA
MN050325800Medicaid
MN0567930001Medicare NSC
MN2220699OtherMEDICA
MN050325800Medicaid