Provider Demographics
NPI:1366573289
Name:PETER S. KLEM, OD
Entity type:Organization
Organization Name:PETER S. KLEM, OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:SHERMAN
Authorized Official - Last Name:KLEM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:2916-652-0449
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-0508
Mailing Address - Country:US
Mailing Address - Phone:916-652-0449
Mailing Address - Fax:916-660-9156
Practice Address - Street 1:3493 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:LOOMIS
Practice Address - State:CA
Practice Address - Zip Code:95650
Practice Address - Country:US
Practice Address - Phone:916-652-0449
Practice Address - Fax:916-660-9156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6478T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty