MEDICARE: KYNDAL KARE

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1467687475
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KYNDAL KARE

Provider Business Mailing Address
First Line	:	794 PEGUES RD
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75603-6616
Country	:	US
Telephone Number	:	903-643-8638
Fax Number	:

Provider Business Practice Location Address
First Line	:	794 PEGUES RD
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75603-6616
Country	:	US
Telephone Number	:	903-261-7386
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DERICK D WATKINS
Credential	:	MT
Telephone Number	:	318-949-9999

Provider Enumeration Date	:	05/19/2009
Last Update Date	:	10/13/2009

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Directions to “KYNDAL KARE ” Practice Location

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