Healthcare Provider Details

I. General information

NPI: 1073556577
Provider Name (Legal Business Name): MICHAEL EUGENE KLAICH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 E SHERWOOD DR
GRAND JUNCTION CO
81501-7578
US

IV. Provider business mailing address

1306 E SHERWOOD DR
GRAND JUNCTION CO
81501-7578
US

V. Phone/Fax

Practice location:
  • Phone: 970-245-5678
  • Fax: 970-245-5679
Mailing address:
  • Phone: 970-245-5678
  • Fax: 970-245-5679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1314
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: