Provider Demographics
NPI:1861818882
Name:KLOVANISH, MARCO (COTA)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:
Last Name:KLOVANISH
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 HIGHWAY 466
Mailing Address - Street 2:UNIT 3106
Mailing Address - City:LADY LAKE
Mailing Address - State:FL
Mailing Address - Zip Code:32159-4252
Mailing Address - Country:US
Mailing Address - Phone:352-573-0136
Mailing Address - Fax:
Practice Address - Street 1:824 HIGHWAY 466
Practice Address - Street 2:UNIT 3106
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-4252
Practice Address - Country:US
Practice Address - Phone:352-573-0136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA1124390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program