Provider Demographics
NPI:1619401445
Name:PETERS, KOLAWOLE
Entity Type:Individual
Prefix:
First Name:KOLAWOLE
Middle Name:
Last Name:PETERS
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 1:7454 N OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1910
Mailing Address - Country:US
Mailing Address - Phone:312-730-3056
Mailing Address - Fax:
Practice Address - Street 1:7454 N OAKLEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-1910
Practice Address - Country:US
Practice Address - Phone:312-730-3056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion