=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003800558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENVER OCCUPATIONAL & AVIATION MED. CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 HAVANA ST SUITE 200
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80239-3240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-373-4456
-----------------------------------------------------
Fax | 303-373-4501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3464 S WILLOW ST
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80231-4531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-755-2900
-----------------------------------------------------
Fax | 303-755-0404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CLARENCE J. KLUCK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 303-373-4456
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 16150
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------