Healthcare Provider Details

I. General information

NPI: 1811128697
Provider Name (Legal Business Name): HENRY BOOTH HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 07/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 S MICHIGAN AVE
CHICAGO IL
60616-5018
US

IV. Provider business mailing address

2850 S MICHIGAN AVE
CHICAGO IL
60616-5018
US

V. Phone/Fax

Practice location:
  • Phone: 312-949-2174
  • Fax: 312-225-6324
Mailing address:
  • Phone: 312-949-2174
  • Fax: 312-225-6324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT PERKINS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 312-949-3609