Basic Information
| Provider Information | |||||||||
| NPI: | 1689150161 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LESTER & ROSALIE ANIXTER CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ANIXTER CENTER AT PARKSHORE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6610 N CLARK ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606264062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737611501 | ||||||||
| FaxNumber: | 7732743523 | ||||||||
| Practice Location | |||||||||
| Address1: | 6125 S KENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606372818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737526000 | ||||||||
| FaxNumber: | 7732743523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2018 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | DESMOND | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 7737611501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | A-0998-0012-A | 05 | IL | MEDICAID |