1003321845 NPI number — STEVEN M KLEEN OPTOMETRIC CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003321845 NPI number — STEVEN M KLEEN OPTOMETRIC CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVEN M KLEEN OPTOMETRIC CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1003321845
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 MAYRUM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA BARBARA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93111-2719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-722-4748
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
701 W CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOMPOC
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93436-2829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-737-1826
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
KLEEN
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
MATTHEW
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
805-722-4748

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  15248TLG , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1376924779 . This is a "NPI TYPE 1 (INDIVIDUAL)" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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