Healthcare Provider Details

I. General information

NPI: 1336244342
Provider Name (Legal Business Name): KENNETH G. WOLF, D.C., L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BAXTER RD SUITE #8
CHESTERFIELD MO
63017-7032
US

IV. Provider business mailing address

12201 FOXPOINT DR
MARYLAND HEIGHTS MO
63043-2109
US

V. Phone/Fax

Practice location:
  • Phone: 314-707-5575
  • Fax: 636-207-6631
Mailing address:
  • Phone: 314-707-5575
  • Fax: 636-207-6631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2006003308
License Number StateMO

VIII. Authorized Official

Name: DR. KENNETH GERARD WOLF
Title or Position: OWNER
Credential: D.C.
Phone: 314-707-5575