MEDICARE: KLR PHYSICIAN GROUP

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	313M00000X	Nursing Facility/Intermediate Care Facility	P3570	TX

General Provider Information

NPI Number	:	1033506456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KLR PHYSICIAN GROUP

Provider Business Mailing Address
First Line	:	3540 E BROAD ST STE 120
Second Line	:
City	:	MANSFIELD
State	:	TX
Zip	:	76063-5633
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3450 E. BROAD STREET
Second Line	:	SUITE 120
City	:	MANSFIELD
State	:	TX
Zip	:	76063-7606
Country	:	US
Telephone Number	:	267-981-0308
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KELLEE L RANDLE
Credential	:	DO
Telephone Number	:	267-981-0308

Provider Enumeration Date	:	04/23/2015
Last Update Date	:	09/11/2025

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Directions to “KLR PHYSICIAN GROUP ” Practice Location

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