Healthcare Provider Details

I. General information

NPI: 1699062521
Provider Name (Legal Business Name): ABRAHAM LINCOLN CENTRE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9020 S STONY ISLAND AVE
CHICAGO IL
60617-3508
US

IV. Provider business mailing address

3858 S COTTAGE GROVE AVE
CHICAGO IL
60653-2089
US

V. Phone/Fax

Practice location:
  • Phone: 773-285-1390
  • Fax: 773-373-6612
Mailing address:
  • Phone: 773-285-1390
  • Fax: 773-373-6626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ZIRL S. SMITH
Title or Position: PRESIDENT & CEO
Credential:
Phone: 773-285-1390