Basic Information
| Provider Information | |||||||||
| NPI: | 1700962974 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLEMM | ||||||||
| FirstName: | KURT | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 586 SHEPARD STREET | ||||||||
| Address2: | |||||||||
| City: | RHINELANDER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7153655252 | ||||||||
| FaxNumber: | 7153655258 | ||||||||
| Practice Location | |||||||||
| Address1: | 528 HWY 70 W | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 54521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7154771523 | ||||||||
| FaxNumber: | 7154771524 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2596 024 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40114400 | 05 | WI | MEDICAID |