1063896298 NPI number — BRETT D VAN KLEY MD

Table of content: BRETT D VAN KLEY MD (NPI 1063896298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063896298 NPI number — BRETT D VAN KLEY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN KLEY
Provider First Name:
BRETT
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063896298
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5074
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5074
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
591 2ND AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDOM
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-831-2223
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  R-10437 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 64557 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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