MEDICARE: LEO KEN WAKEFIELD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156FX1800X	Optician

General Provider Information

NPI Number	:	1760674162
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEO KEN WAKEFIELD

Provider Business Mailing Address
First Line	:	2960 E 2ND AVE
Second Line	:	SUITE C
City	:	DENVER
State	:	CO
Zip	:	80206-4924
Country	:	US
Telephone Number	:	303-322-7507
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 FILLMORE ST
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80206-4916
Country	:	US
Telephone Number	:	303-321-3000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2007
Last Update Date	:	08/10/2007

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Directions to “ LEO KEN WAKEFIELD ” Practice Location

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