Provider Demographics
NPI:1295334589
Name:KLUCAR, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:KLUCAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21970 SR 664
Mailing Address - Street 2:
Mailing Address - City:SOUTH BLOOMINGVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43152
Mailing Address - Country:US
Mailing Address - Phone:740-279-9013
Mailing Address - Fax:
Practice Address - Street 1:1389 OHIO AVE LOT 40
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-9612
Practice Address - Country:US
Practice Address - Phone:740-279-9013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0337369Medicaid