MEDICARE: LUTHERAN SOCIAL SERVICES OF ILLINOIS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	A-0286-0003-A	IL

General Provider Information

NPI Number	:	1780893859
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUTHERAN SOCIAL SERVICES OF ILLINOIS

Provider Business Mailing Address
First Line	:	1001 E TOUHY AVE
Second Line	:	SUITE# 170
City	:	DES PLAINES
State	:	IL
Zip	:	60018-5801
Country	:	US
Telephone Number	:	847-635-4600
Fax Number	:	847-297-3407

Provider Business Practice Location Address
First Line	:	1758 W DEVON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1130
Country	:	US
Telephone Number	:	773-764-4350
Fax Number	:	773-764-5313

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. GERALD NOONAN
Credential	:
Telephone Number	:	847-635-4600

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	08/22/2020

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