Healthcare Provider Details

I. General information

NPI: 1942161724
Provider Name (Legal Business Name): URBAN LODGE SUPPORTIVE LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2025
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

762 PULASKI RD
CALUMET CITY IL
60409-4018
US

IV. Provider business mailing address

762 PULASKI RD
CALUMET CITY IL
60409-4018
US

V. Phone/Fax

Practice location:
  • Phone: 708-735-1123
  • Fax:
Mailing address:
  • Phone: 708-735-1123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: IESHA SHANAE HAIRSTON
Title or Position: OWNER
Credential: LPN
Phone: 708-735-1123