1043450562 NPI number — OMNI YOUTH SERVICES

Table of content: (NPI 1043450562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043450562 NPI number — OMNI YOUTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMNI YOUTH SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
OMNI YOUTH SERVICES-ELA
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043450562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 W LAKE COOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFFALO GROVE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60089-1926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-353-1500
Provider Business Mailing Address Fax Number:
847-465-1964

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1025 OLD MCHENRY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ZURICH
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60047-8428
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-540-0680
Provider Business Practice Location Address Fax Number:
847-540-1427
Provider Enumeration Date:
02/24/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
EGGER
Authorized Official First Name:
SHANAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
847-353-1762

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  08005 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 08005 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".