Provider Demographics
NPI:1184185159
Name:KENTON WADSWORTH LLC
Entity Type:Organization
Organization Name:KENTON WADSWORTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENTON
Authorized Official - Middle Name:
Authorized Official - Last Name:WADSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-946-4755
Mailing Address - Street 1:44150 W 12 MILE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2649
Mailing Address - Country:US
Mailing Address - Phone:248-946-4755
Mailing Address - Fax:
Practice Address - Street 1:44150 W 12 MILE RD STE 300
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2649
Practice Address - Country:US
Practice Address - Phone:248-946-4755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-30
Last Update Date:2019-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty