Healthcare Provider Details

I. General information

NPI: 1568668648
Provider Name (Legal Business Name): MICHAEL JOHN KLINGER CST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 E. JIRON ST
ESPANOLA NM
87532
US

IV. Provider business mailing address

615 E. JIRON ST./ APT. #2
ESPANOLA NM
87532
US

V. Phone/Fax

Practice location:
  • Phone: 517-581-0021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: