Healthcare Provider Details

I. General information

NPI: 1245439728
Provider Name (Legal Business Name): ROBERT E. KLENCK M.D. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD 1090
SANTA MONICA CA
90404-2102
US

IV. Provider business mailing address

215 13TH ST
SEAL BEACH CA
90740-6502
US

V. Phone/Fax

Practice location:
  • Phone: 310-582-7475
  • Fax:
Mailing address:
  • Phone: 818-907-7828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberG60894
License Number StateCA

VIII. Authorized Official

Name: ROBERT E KLENCK
Title or Position: PHYSICAN
Credential: M.D.
Phone: 818-907-7828