Provider Demographics
NPI:1558560615
Name:WOLOSZ, KENNETH JOHN (DC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name:WOLOSZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:413 WANAQUE AVE
Mailing Address - Street 2:
Mailing Address - City:POMPTON LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07442-1844
Mailing Address - Country:US
Mailing Address - Phone:973-831-7703
Mailing Address - Fax:973-831-6763
Practice Address - Street 1:413 WANAQUE AVE
Practice Address - Street 2:
Practice Address - City:POMPTON LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07442-1844
Practice Address - Country:US
Practice Address - Phone:973-831-7703
Practice Address - Fax:973-831-6763
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3479111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJWO453427Medicare PIN