1336317080 NPI number — STEVEN KLECKER

Table of content: (NPI 1336317080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336317080 NPI number — STEVEN KLECKER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVEN KLECKER
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:
STEVEN KLECKER OPTOMETRIST
Provider Other Organization Name Type Code:
5
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:
1336317080
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1555 E NEW CIRCLE RD STE 146
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40509-1044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-269-6921
Provider Business Mailing Address Fax Number:
859-266-9504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 E NEW CIRCLE RD STE 146
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40509-1044
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-269-6921
Provider Business Practice Location Address Fax Number:
859-266-9504
Provider Enumeration Date:
02/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KLECKER
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
AMBROSE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
859-269-6921

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  KY844DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 77008449 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9836 . This is a "MEDICARE GROUP ID" identifier . This identifiers is of the category "OTHER".




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