Provider Demographics
NPI:1114996287
Name:WOLFORD, KENNETH C (CSA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:C
Last Name:WOLFORD
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7078 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133
Mailing Address - Country:US
Mailing Address - Phone:813-854-1664
Mailing Address - Fax:630-378-1740
Practice Address - Street 1:7078 WEST AVE
Practice Address - Street 2:
Practice Address - City:HANOVER PARK
Practice Address - State:IL
Practice Address - Zip Code:60133
Practice Address - Country:US
Practice Address - Phone:630-378-1225
Practice Address - Fax:630-378-1740
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL23B.000007174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist