Provider Demographics
NPI:1972627511
Name:KLEIN EYE CARE I, INC
Entity type:Organization
Organization Name:KLEIN EYE CARE I, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-883-5665
Mailing Address - Street 1:21530 HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:STE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-8813
Mailing Address - Country:US
Mailing Address - Phone:573-883-5665
Mailing Address - Fax:573-883-5661
Practice Address - Street 1:21530 HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:STE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-8813
Practice Address - Country:US
Practice Address - Phone:573-883-5665
Practice Address - Fax:573-883-5661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02815152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO312898638Medicaid
MODG8301OtherPALMETTO GBA
MO5294680001Medicare NSC
MO312898638Medicaid