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General NPI Number Information
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NPI Number | 1093860603
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Entity Type | Individual
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Provider Name | KENNETH JOE KORESCH OD
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Gender | Male
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 09/11/2009
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Provider Practice Location Address
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Address Line | 1987 W GALENA BLVD.
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City | AURORA
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State | IL
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Zip | 60506-4305
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Country | US
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Telephone | 630-892-6610
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Fax | 630-892-6619
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Provider Business Mailing Address
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Address Line | 5308 GRAND AVE
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City | DOWNERS GROVE
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State | IL
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Zip | 60515-5118
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Country | US
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Telephone | 630-960-4167
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 046007057
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License Number State | IL
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