Healthcare Provider Details

I. General information

NPI: 1326876525
Provider Name (Legal Business Name): LOVE MANIA CLUB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 11/01/2024
Certification Date: 11/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 E 50TH ST APT 2C
CHICAGO IL
60615-2597
US

IV. Provider business mailing address

613 E 50TH ST APT 2C
CHICAGO IL
60615-2597
US

V. Phone/Fax

Practice location:
  • Phone: 773-629-7477
  • Fax:
Mailing address:
  • Phone: 773-629-7477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: BEUNKA BUTLER
Title or Position: EXECUTIVE DIRECTOR
Credential: CADC, CHW, BA
Phone: 773-629-7477