1871591552 NPI number — MR. KENNETH ANDREW KLOOS P.T.

Table of content: MR. KENNETH ANDREW KLOOS P.T. (NPI 1871591552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871591552 NPI number — MR. KENNETH ANDREW KLOOS P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KLOOS
Provider First Name:
KENNETH
Provider Middle Name:
ANDREW
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KLOOS
Provider Other First Name:
K
Provider Other Middle Name:
ANDREW
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1871591552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2241 SUNSET BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
ROCKLIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95765-4230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-435-8950
Provider Business Mailing Address Fax Number:
916-435-8951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2241 SUNSET BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ROCKLIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95765-4230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-435-8950
Provider Business Practice Location Address Fax Number:
916-435-8951
Provider Enumeration Date:
07/07/2005

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: 225100000X , with the licence number:  PT 14730 , 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: 4731926-5 . This is a "EMPLOYMENT DEVELOPMENT DE" identifier . This identifiers is of the category "OTHER".




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