Provider Demographics
NPI:1366600082
Name:PETER S. KLEM FRED P. GUARCELLO PTR
Entity type:Organization
Organization Name:PETER S. KLEM FRED P. GUARCELLO PTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:GUARCELLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:209-527-7784
Mailing Address - Street 1:4028 DALE ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9561
Mailing Address - Country:US
Mailing Address - Phone:209-527-7784
Mailing Address - Fax:209-527-5079
Practice Address - Street 1:4028 DALE ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9561
Practice Address - Country:US
Practice Address - Phone:209-527-7784
Practice Address - Fax:209-527-5079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366600082Medicaid
CABB022BMedicare PIN