Provider Demographics
NPI:1033368493
Name:KACZMAREK, KENNETH ANDREW (PBT-ASCP)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ANDREW
Last Name:KACZMAREK
Suffix:
Gender:M
Credentials:PBT-ASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38463 NORTH 9TH STREET
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081-9017
Mailing Address - Country:US
Mailing Address - Phone:847-973-2188
Mailing Address - Fax:847-973-2644
Practice Address - Street 1:38463 NORTH 9TH STREET
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081-9017
Practice Address - Country:US
Practice Address - Phone:847-973-2188
Practice Address - Fax:847-973-2644
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL04172088-ASCP174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist