Healthcare Provider Details

I. General information

NPI: 1720565997
Provider Name (Legal Business Name): DUSTIN KELM THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2018
Last Update Date: 07/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3389 MCGREGOR SOUTH LOOP
MC GREGOR TX
76657-4082
US

IV. Provider business mailing address

PO BOX 184
LORENA TX
76655-0184
US

V. Phone/Fax

Practice location:
  • Phone: 254-723-5058
  • Fax: 254-857-2007
Mailing address:
  • Phone: 254-723-5058
  • Fax: 254-857-2007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1237757
License Number StateTX

VIII. Authorized Official

Name: DR. DUSTIN DWAIN KELM
Title or Position: OWNER
Credential: PT, DPT
Phone: 254-723-5058