Provider Demographics
NPI:1003321845
Name:STEVEN M KLEEN OPTOMETRIC CORPORATION
Entity Type:Organization
Organization Name:STEVEN M KLEEN OPTOMETRIC CORPORATION
Other - Org Name:KLEEN OPTOMETRY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:KLEEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:805-722-4748
Mailing Address - Street 1:640 MAYRUM ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93111-2719
Mailing Address - Country:US
Mailing Address - Phone:805-722-4748
Mailing Address - Fax:
Practice Address - Street 1:701 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2829
Practice Address - Country:US
Practice Address - Phone:805-737-1826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15248TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1376924779OtherNPI TYPE 1 (INDIVIDUAL)