Healthcare Provider Details

I. General information

NPI: 1194413013
Provider Name (Legal Business Name): MR. JOHN O KLOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MONROE AVE NW
GRAND RAPIDS MI
49503-1455
US

IV. Provider business mailing address

338 PARKSIDE LN
DOUGLAS MI
49406-5120
US

V. Phone/Fax

Practice location:
  • Phone: 616-259-7207
  • Fax: 616-259-7261
Mailing address:
  • Phone: 616-240-2021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: