Healthcare Provider Details

I. General information

NPI: 1063708832
Provider Name (Legal Business Name): MATTHEW KLECAN B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 06/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 DOMINGO RD NE
ALBUQUERQUE NM
87108-1610
US

IV. Provider business mailing address

PO BOX 80982
ALBUQUERQUE NM
87198-0982
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-5295
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number105341
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: