1386671279 NPI number — SOUTH HAVEN BEHAVIORAL MODIFICATION II INC

Table of content: (NPI 1386671279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386671279 NPI number — SOUTH HAVEN BEHAVIORAL MODIFICATION II INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH HAVEN BEHAVIORAL MODIFICATION II INC
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:
Provider Other Organization Name Type Code:
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:
1386671279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4632 175TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COUNTRY CLUB HILLS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60478-4531
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-785-6597
Provider Business Mailing Address Fax Number:
706-206-0550

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
448-454 E. 61ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-752-8602
Provider Business Practice Location Address Fax Number:
773-752-5824
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PIMENTEL
Authorized Official First Name:
DANTE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
773-752-8602

Provider Taxonomy Codes

  • Taxonomy code: 103TP2701X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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