Provider Demographics
NPI:1083223622
Name:KLOAK, RONNIE PEEREA
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:PEEREA
Last Name:KLOAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 SE LAKE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7759
Mailing Address - Country:US
Mailing Address - Phone:503-344-6711
Mailing Address - Fax:
Practice Address - Street 1:2100 SE LAKE RD STE 1
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7759
Practice Address - Country:US
Practice Address - Phone:503-344-6711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-29
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25770225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist