Healthcare Provider Details

I. General information

NPI: 1366573289
Provider Name (Legal Business Name): PETER S. KLEM, OD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3493 TAYLOR RD
LOOMIS CA
95650
US

IV. Provider business mailing address

PO BOX 508
LOOMIS CA
95650-0508
US

V. Phone/Fax

Practice location:
  • Phone: 916-652-0449
  • Fax: 916-660-9156
Mailing address:
  • Phone: 916-652-0449
  • Fax: 916-660-9156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6478T
License Number StateCA

VIII. Authorized Official

Name: PETER SHERMAN KLEM
Title or Position: OWNER
Credential: OD
Phone: 29166520449