Basic Information
| Provider Information | |||||||||
| NPI: | 1932318920 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LUTHERAN SOCIAL SERVICES OF ILLINOIS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BHS KENMORE FACILITY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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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: | 5517 N KENMORE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606401515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732757962 | ||||||||
| FaxNumber: | 7732750728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STUTRUD | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8473904651 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | A-0286-0011-A | IL | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 324500000X | A-0286-0008-A | IL | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 324500000X | A-0286-0012-A | IL | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QR0405X | A-0286-0009-A | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.