Healthcare Provider Details

I. General information

NPI: 1144866724
Provider Name (Legal Business Name): INFINITE POSSIBILITIES FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 11/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12511 S PRINCETON AVE
CHICAGO IL
60628-7224
US

IV. Provider business mailing address

12511 S PRINCETON AVE
CHICAGO IL
60628-7224
US

V. Phone/Fax

Practice location:
  • Phone: 312-826-1210
  • Fax:
Mailing address:
  • Phone: 312-826-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. CONNIE TEMPLE
Title or Position: CEO
Credential:
Phone: 312-826-1210