Healthcare Provider Details

I. General information

NPI: 1619401445
Provider Name (Legal Business Name): KOLAWOLE PETERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7454 N OAKLEY AVE
CHICAGO IL
60645-1910
US

IV. Provider business mailing address

7454 N OAKLEY AVE
CHICAGO IL
60645-1910
US

V. Phone/Fax

Practice location:
  • Phone: 312-730-3056
  • Fax:
Mailing address:
  • Phone: 312-730-3056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: