1578839700 NPI number — FAMILY ADOLESCENT CHILD TREATMENT SERVICE LLC

Table of content: DR. JOHN CHARLES HUNZIKER PH.D. (NPI 1063491512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578839700 NPI number — FAMILY ADOLESCENT CHILD TREATMENT SERVICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY ADOLESCENT CHILD TREATMENT SERVICE LLC
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:
1578839700
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4801 W PETERSON AVE
Provider Second Line Business Mailing Address:
401
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60646-5713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-282-2322
Provider Business Mailing Address Fax Number:
773-282-2853

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4801 W PETERSON AVE
Provider Second Line Business Practice Location Address:
401
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60646-5713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-282-2322
Provider Business Practice Location Address Fax Number:
773-282-2853
Provider Enumeration Date:
04/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
BOHO
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
MARY
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
773-282-2322

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X , with the licence number:  071004665 , 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)





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