Provider Demographics
NPI:1841535465
Name:KLEM, MARK (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KLEM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HARVEST
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3234
Mailing Address - Country:US
Mailing Address - Phone:949-677-5029
Mailing Address - Fax:949-654-8715
Practice Address - Street 1:12 HARVEST
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3234
Practice Address - Country:US
Practice Address - Phone:949-677-5029
Practice Address - Fax:949-654-8715
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA181762251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics