1801336961 NPI number — IT'S ABOUT CHANGE SOBER LIVING, INC.

Table of content: (NPI 1801336961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801336961 NPI number — IT'S ABOUT CHANGE SOBER LIVING, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IT'S ABOUT CHANGE SOBER LIVING, 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:
1801336961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
394 MADISON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALUMET CITY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60409-2107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-868-5014
Provider Business Mailing Address Fax Number:
708-868-8335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1604 HORBOR ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALUMET CITY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-360-3205
Provider Business Practice Location Address Fax Number:
708-868-8335
Provider Enumeration Date:
03/08/2017

Additional Information

Authorized Official

Authorized Official Last Name:
DILLARD
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
708-772-5014

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  A-8723-0003-A , 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: C/A-8723-0003-A , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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