Healthcare Provider Details

I. General information

NPI: 1396723300
Provider Name (Legal Business Name): JON A KLINE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7351 LAKE SHORE BLVD
MENTOR OH
44060-3552
US

IV. Provider business mailing address

7351 LAKE SHORE BLVD
MENTOR OH
44060-3552
US

V. Phone/Fax

Practice location:
  • Phone: 440-257-4311
  • Fax: 440-257-0666
Mailing address:
  • Phone: 440-257-4311
  • Fax: 440-257-0666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2986 T748
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: