Healthcare Provider Details

I. General information

NPI: 1295908689
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W GALENA BLVD
AURORA IL
60506-3855
US

IV. Provider business mailing address

1001 E TOUHY AVE SUITE 170
DES PLAINES IL
60018-5801
US

V. Phone/Fax

Practice location:
  • Phone: 630-892-8418
  • Fax: 630-892-8452
Mailing address:
  • Phone: 847-635-4600
  • Fax: 847-297-3407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number926169
License Number StateIL

VIII. Authorized Official

Name: MR. JERRY NOONAN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 847-635-4600