=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164738027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KPT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2010
-----------------------------------------------------
Last Update Date | 03/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 E SAN MARNAN DR
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50702-5837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-239-5009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 315 E SAN MARNAN DR
-----------------------------------------------------
City | WATERLOO
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50702-5837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-239-5009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFREY ALAN KEMP
-----------------------------------------------------
Credential | MS PT
-----------------------------------------------------
Telephone | 319-239-5009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 02099
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------