1093394124 NPI number — AUTISM CLINIC CORP

Table of content: (NPI 1093394124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093394124 NPI number — AUTISM CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUTISM CLINIC CORP
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:
AUTISM CLINIC
Provider Other Organization Name Type Code:
4
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:
1093394124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7255 GEORGETOWN CMNS
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRANKFORT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60423-3001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-378-4550
Provider Business Mailing Address Fax Number:
630-920-0552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7255 GEORGETOWN CMNS
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKFORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60423-3001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-378-4550
Provider Business Practice Location Address Fax Number:
630-920-0552
Provider Enumeration Date:
04/06/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KASSAR
Authorized Official First Name:
SHADEN
Authorized Official Middle Name:
S
Authorized Official Title or Position:
ADMINSTOR
Authorized Official Telephone Number:
630-631-9623

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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