MEDICARE: MR. KENNETH WADE KLARE LPT

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	1096576	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7019083	OTHER	TX	AETNA HEALTHCARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	83755T	OTHER	TX	BCBS OF TEXAS
4	6400153	OTHER	TX	UNITED HEALTHCARE

General Provider Information

NPI Number	:	1861491961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH WADE KLARE LPT

Provider Business Mailing Address
First Line	:	702 E MIMOSA ST
Second Line	:
City	:	ROCKPORT
State	:	TX
Zip	:	78382-4151
Country	:	US
Telephone Number	:	361-729-8838
Fax Number	:	361-729-9508

Provider Business Practice Location Address
First Line	:	702 E MIMOSA ST
Second Line	:
City	:	ROCKPORT
State	:	TX
Zip	:	78382-4151
Country	:	US
Telephone Number	:	361-729-8838
Fax Number	:	361-729-9508

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

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	04/05/2012

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