1760806350 NPI number — LOUDEK COMMUNITY SERVICES, INC.

Table of content: (NPI 1760806350)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760806350 NPI number — LOUDEK COMMUNITY SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOUDEK 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:
Provider Other Organization Name Type Code:
6
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:
1760806350
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10540 S WESTERN AVE STE 402
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:
60643-2529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-253-7052
Provider Business Mailing Address Fax Number:
773-253-7051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10540 S WESTERN AVE
Provider Second Line Business Practice Location Address:
STE # 402
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60643-2536
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-253-7052
Provider Business Practice Location Address Fax Number:
773-253-7051
Provider Enumeration Date:
02/18/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MARSHALL
Authorized Official First Name:
EMMITT
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHAIRPERSON
Authorized Official Telephone Number:
773-253-7052

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  2278614 , 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: 819206 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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