Provider Demographics
NPI:1417353368
Name:WOOD, KENNETH III
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WOOD
Suffix:III
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 1:1123 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHANUTE
Mailing Address - State:KS
Mailing Address - Zip Code:66720-2953
Mailing Address - Country:US
Mailing Address - Phone:620-212-0446
Mailing Address - Fax:
Practice Address - Street 1:1123 S EVERGREEN AVE
Practice Address - Street 2:
Practice Address - City:CHANUTE
Practice Address - State:KS
Practice Address - Zip Code:66720-2953
Practice Address - Country:US
Practice Address - Phone:620-212-0446
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications