Healthcare Provider Details

I. General information

NPI: 1093721219
Provider Name (Legal Business Name): WOODSON CENTER FOR ADULT HEALTHCARE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 DIXIE HWY
CHICAGO HEIGHTS IL
60411-1770
US

IV. Provider business mailing address

PO BOX 1097
BEDFORD PARK IL
60499-1097
US

V. Phone/Fax

Practice location:
  • Phone: 708-709-9200
  • Fax: 708-756-0348
Mailing address:
  • Phone: 708-709-9200
  • Fax: 708-756-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number036076317
License Number StateIL

VIII. Authorized Official

Name: LYNNETTE MCROY
Title or Position: BILLING COORDINATOR
Credential:
Phone: 773-767-3822