Basic Information
| Provider Information | |||||||||
| NPI: | 1659863835 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLOC | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | MARGARET | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5458 ERIE STATION LN APT 67 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452272585 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179380410 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8118 CORPORATE WAY | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450407350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139478433 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2018 | ||||||||
| LastUpdateDate: | 06/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156F00000X | Y | Eye and Vision Services Providers | Technician/Technologist |
ID Information
| ID | Type | State | Issuer | Description | 37966 | 01 | BLUE CROSS BLUE SHIELD OF ALABAMA | OTHER |