Provider Demographics
NPI:1033506456
Name:KLR PHYSICIAN GROUP
Entity Type:Organization
Organization Name:KLR PHYSICIAN GROUP
Other - Org Name:THE KLR PHYSICIAN GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:RANDLE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:267-981-0308
Mailing Address - Street 1:3540 E BROAD ST STE 120
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3450 E. BROAD STREET
Practice Address - Street 2:SUITE 120
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-7606
Practice Address - Country:US
Practice Address - Phone:267-981-0308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-23
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3570313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility