Basic Information
| Provider Information | |||||||||
| NPI: | 1922634021 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 E TOUHY AVE STE 50 | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600185817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476354600 | ||||||||
| FaxNumber: | 8472973407 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 N CHERRY ST | ||||||||
| Address2: | |||||||||
| City: | MORRISON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612702605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157724044 | ||||||||
| FaxNumber: | 8157727944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2020 | ||||||||
| LastUpdateDate: | 03/20/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAMBLET | ||||||||
| AuthorizedOfficialFirstName: | GREERANN | ||||||||
| AuthorizedOfficialMiddleName: | LOVETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8473901422 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/20/2020 | ||||||||
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-0286-005-A | 05 | IL | MEDICAID |