Healthcare Provider Details

I. General information

NPI: 1629721816
Provider Name (Legal Business Name): KILPATRICK RENAISSANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2022
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4655 W BERTEAU AVE
CHICAGO IL
60641-2647
US

IV. Provider business mailing address

2501 W WASHINGTON BLVD STE 401
CHICAGO IL
60612-2127
US

V. Phone/Fax

Practice location:
  • Phone: 773-645-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BANGHART
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 773-645-8900