Provider Demographics
NPI:1871591552
Name:KLOOS, KENNETH ANDREW (PT)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ANDREW
Last Name:KLOOS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:K
Other - Middle Name:ANDREW
Other - Last Name:KLOOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2241 SUNSET BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-4230
Mailing Address - Country:US
Mailing Address - Phone:916-435-8950
Mailing Address - Fax:916-435-8951
Practice Address - Street 1:2241 SUNSET BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-4230
Practice Address - Country:US
Practice Address - Phone:916-435-8950
Practice Address - Fax:916-435-8951
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 14730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4731926-5OtherEMPLOYMENT DEVELOPMENT DE
147300Medicare ID - Type Unspecified
P36598Medicare UPIN