Provider Demographics
NPI:1154353084
Name:HART, KENNETH WESLEY
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:WESLEY
Last Name:HART
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1742 SAYLES BLVD
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79605-6032
Mailing Address - Country:US
Mailing Address - Phone:325-665-6736
Mailing Address - Fax:325-701-4044
Practice Address - Street 1:1742 SAYLES BLVD
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79605-6032
Practice Address - Country:US
Practice Address - Phone:325-665-6736
Practice Address - Fax:325-701-4044
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX147670311ZA0620X, 311Z00000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001013257Medicaid
TX001013257OtherCCAD