Healthcare Provider Details

I. General information

NPI: 1053742221
Provider Name (Legal Business Name): DUSTIN DWAIN KELM PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 LAUREL DR.
WACO TX
76710
US

IV. Provider business mailing address

PO BOX 184
LORENA TX
76655-0184
US

V. Phone/Fax

Practice location:
  • Phone: 254-399-6633
  • Fax:
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:
Title or Position:
Credential:
Phone: