Provider Demographics
NPI:1730594482
Name:PERTEET, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:PERTEET
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 W WABANSIA AVE
Mailing Address - Street 2:APT. #1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4936
Mailing Address - Country:US
Mailing Address - Phone:773-543-5140
Mailing Address - Fax:708-575-9439
Practice Address - Street 1:3269 W WABANSIA AVE
Practice Address - Street 2:APT. #1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4936
Practice Address - Country:US
Practice Address - Phone:773-543-5140
Practice Address - Fax:708-575-9439
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILP63351178057172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver