Provider Demographics
NPI:1932215498
Name:WOLF, KENNETH GERARD (DC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:GERARD
Last Name:WOLF
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4627 TAUNEYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2219
Mailing Address - Country:US
Mailing Address - Phone:314-707-5575
Mailing Address - Fax:
Practice Address - Street 1:1276A JUNGERMANN RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-6961
Practice Address - Country:US
Practice Address - Phone:314-707-5575
Practice Address - Fax:636-794-3012
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006003308111N00000X
IL038-009874111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038009874Medicaid
ILU94849Medicare UPIN
IL205493Medicare ID - Type Unspecified