MEDICARE: DR. KENNETH LAWRENCE MILLER PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1315748	TX
2	225100000X	Physical Therapist	015564	NY

General Provider Information

NPI Number	:	1003036351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH LAWRENCE MILLER PT, DPT

Provider Business Mailing Address
First Line	:	6033 FOREST LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-1059
Country	:	US
Telephone Number	:	631-697-4681
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2644
Country	:	US
Telephone Number	:	817-735-5466
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2007
Last Update Date	:	05/25/2021

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