Provider Demographics
NPI:1992029706
Name:KENNETH J KLAK DO LLC
Entity Type:Organization
Organization Name:KENNETH J KLAK DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KLAK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:440-799-4433
Mailing Address - Street 1:1440 ROCKSIDE RD
Mailing Address - Street 2:314
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-2774
Mailing Address - Country:US
Mailing Address - Phone:440-799-4433
Mailing Address - Fax:440-799-4437
Practice Address - Street 1:1440 ROCKSIDE RD
Practice Address - Street 2:314
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-2774
Practice Address - Country:US
Practice Address - Phone:440-799-4433
Practice Address - Fax:440-799-4437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-23
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34002229207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3034326Medicaid