Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT-001913 | KY |
NPI | 1003273350 |
---|---|
Provider Name | Mark Kleckner |
First Address | Lexington, KY 40511-2028 |
Second Address | Lexington, KY 40511-2028 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/01/2016 |
Last Update Date | 18/01/2016 |