1538411764 NPI number — ADA S. MCKINLEY COMMUNITY SERVICES, INC.

Table of content: (NPI 1538411764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538411764 NPI number — ADA S. MCKINLEY COMMUNITY SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADA S. MCKINLEY COMMUNITY SERVICES, 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:
DAVIS HOUSE
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:
1538411764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1359 W WASHINGTON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60607-1905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-385-2000
Provider Business Mailing Address Fax Number:
312-554-0292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4237 S INDIANA AVE
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:
60653-3213
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-373-1044
Provider Business Practice Location Address Fax Number:
773-373-2387
Provider Enumeration Date:
10/11/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
REE
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF QUALITY ASSURANCE
Authorized Official Telephone Number:
312-385-2031

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320600000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0030585 . This is a "IDPH LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".