Provider Demographics
NPI:1497927875
Name:MICHAEL E. KLAICH, O.D.
Entity Type:Organization
Organization Name:MICHAEL E. KLAICH, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWELLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-245-5678
Mailing Address - Street 1:1306 E SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81501-7578
Mailing Address - Country:US
Mailing Address - Phone:970-245-5678
Mailing Address - Fax:970-245-5679
Practice Address - Street 1:1306 E SHERWOOD DR
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-7578
Practice Address - Country:US
Practice Address - Phone:970-245-5678
Practice Address - Fax:970-245-5679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1314152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1008470001Medicare NSC
COC41733Medicare PIN