1134376403 NPI number — PROVISO FAMILY SERVICES

Table of content: (NPI 1134376403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134376403 NPI number — PROVISO FAMILY SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROVISO FAMILY 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:
RESURRECTION BEHAVIORAL HEALTH
Provider Other Organization Name Type Code:
3
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:
1134376403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1820 S 25TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROADVIEW
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60155-2864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-338-3806
Provider Business Mailing Address Fax Number:
708-681-1289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 W LAKE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MELROSE PARK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60160-4039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-681-2324
Provider Business Practice Location Address Fax Number:
708-345-5496
Provider Enumeration Date:
08/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KAMISKI
Authorized Official First Name:
KRISTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER, GENERAL ACCOUNTING
Authorized Official Telephone Number:
708-338-3806

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1616087 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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