Basic Information
Provider Information
NPI: 1730653247
EntityType: 2
ReplacementNPI:  
OrganizationName: LESTER & ROSALIE ANIXTER CENTER
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6610 N CLARK ST
Address2:  
City: CHICAGO
State: IL
PostalCode: 606264062
CountryCode: US
TelephoneNumber: 7737611501
FaxNumber: 7732743523
Practice Location
Address1: 8001 S WESTERN AVE
Address2:  
City: CHICAGO
State: IL
PostalCode: 606205930
CountryCode: US
TelephoneNumber: 7737611501
FaxNumber: 7732743523
Other Information
ProviderEnumerationDate: 01/17/2019
LastUpdateDate: 01/17/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: OLKOWSKI
AuthorizedOfficialFirstName: HEIDI
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: CLAIMS SPECIALIST
AuthorizedOfficialTelephone: 7737611501
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QR0405X  Y Ambulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder

ID Information
IDTypeStateIssuerDescription
A-0098-0014-A05IL MEDICAID


Home