Provider Demographics
NPI:1861491961
Name:KLARE, KENNETH WADE (LPT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:WADE
Last Name:KLARE
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 E MIMOSA ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:TX
Mailing Address - Zip Code:78382-4151
Mailing Address - Country:US
Mailing Address - Phone:361-729-8838
Mailing Address - Fax:361-729-9508
Practice Address - Street 1:702 E MIMOSA ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:TX
Practice Address - Zip Code:78382-4151
Practice Address - Country:US
Practice Address - Phone:361-729-8838
Practice Address - Fax:361-729-9508
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-20
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1096576225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7019083OtherAETNA HEALTHCARE
TN0632119-01Medicaid
TX83755TOtherBCBS OF TEXAS
TX6400153OtherUNITED HEALTHCARE
TX7019083OtherAETNA HEALTHCARE