Healthcare Provider Details

I. General information

NPI: 1013515501
Provider Name (Legal Business Name): AV360 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 LAKE COOK RD
ALGONQUIN IL
60102-5447
US

IV. Provider business mailing address

2140 LAKE COOK RD
ALGONQUIN IL
60102-5447
US

V. Phone/Fax

Practice location:
  • Phone: 224-333-0948
  • Fax: 224-228-2822
Mailing address:
  • Phone: 224-333-0948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: BETSY KOSTKA
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 224-520-0390