Provider Demographics
NPI:1356692404
Name:KL MEDICAL CLINIC, LLC.
Entity type:Organization
Organization Name:KL MEDICAL CLINIC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:OFOHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-773-7909
Mailing Address - Street 1:PO BOX 492110
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049-0036
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:905 PARKSIDE WALK LN STE 100A
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-7314
Practice Address - Country:US
Practice Address - Phone:678-442-9486
Practice Address - Fax:678-442-9488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-28
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA68463261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center