=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407414246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTIN ROBERT KLIMCHAK OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2019
-----------------------------------------------------
Last Update Date | 08/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 ROBINSON CENTER DR STE 2870
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15205-4831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-490-0820
-----------------------------------------------------
Fax | 412-490-2570
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 ROCKY MOUNTAIN CT
-----------------------------------------------------
City | LATROBE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15650-2409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-244-3455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OEG003521
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------