MEDICARE: VICTOR D KENNEL PT

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	1060564	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730170309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTOR D KENNEL PT

Provider Business Mailing Address
First Line	:	PO BOX 610393
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75261-0393
Country	:	US
Telephone Number	:	903-291-6187
Fax Number	:	903-237-1810

Provider Business Practice Location Address
First Line	:	707 HOLLYBROOK DR
Second Line	:	SUITE 500
City	:	LONGVIEW
State	:	TX
Zip	:	75605-2410
Country	:	US
Telephone Number	:	903-291-6113
Fax Number	:	903-234-9126

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	09/24/2019

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Directions to “ VICTOR D KENNEL PT” Practice Location

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