Basic Information
Provider Information | |||||||||
NPI: | 1174926869 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | INTOUCH HOME CARE SERVICES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1001 E TOUHY AVE | ||||||||
Address2: | SUITE 300 | ||||||||
City: | DES PLAINES | ||||||||
State: | IL | ||||||||
PostalCode: | 600185801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8476354600 | ||||||||
FaxNumber: | 8476995117 | ||||||||
Practice Location | |||||||||
Address1: | 4011 AVENUE OF THE CITIES | ||||||||
Address2: | SUITE 102 | ||||||||
City: | MOLINE | ||||||||
State: | IL | ||||||||
PostalCode: | 612654454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3097970200 | ||||||||
FaxNumber: | 3097975135 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/08/2014 | ||||||||
LastUpdateDate: | 09/23/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STUTRUD | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8476354600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | 3000753 | IL | N |   | Agencies | In Home Supportive Care |   | 251B00000X |   |   | N |   | Agencies | Case Management |   | 261QA0600X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
No ID Information.