Healthcare Provider Details

I. General information

NPI: 1336122142
Provider Name (Legal Business Name): GREGORY DONALD KLYCZEK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2005
Last Update Date: 03/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24767 LORAIN RD
NORTH OLMSTED OH
44070-2070
US

IV. Provider business mailing address

4040 W 229TH ST
FAIRVIEW PARK OH
44126-1080
US

V. Phone/Fax

Practice location:
  • Phone: 440-777-3595
  • Fax:
Mailing address:
  • Phone: 440-779-9822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2409
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: