1063678761 NPI number — JOYOUS YEARS

Table of content: (NPI 1063678761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063678761 NPI number — JOYOUS YEARS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOYOUS YEARS
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:
1063678761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 MANCHESTER RD
Provider Second Line Business Mailing Address:
BUILDING A SUITE 615
Provider Business Mailing Address City Name:
WHEATON
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60187-4579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-384-1254
Provider Business Mailing Address Fax Number:
630-260-4120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 E 75TH 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:
60619-1420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-384-1254
Provider Business Practice Location Address Fax Number:
630-384-1217
Provider Enumeration Date:
08/01/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROLLS
Authorized Official First Name:
KEISHA
Authorized Official Middle Name:
Authorized Official Title or Position:
SENIOR PROJECT MANAGER
Authorized Official Telephone Number:
630-384-1254

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  036100650 , 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: 036100650 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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