Healthcare Provider Details

I. General information

NPI: 1063720282
Provider Name (Legal Business Name): CHILDREN'S RESEARCH TRIANGLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 N MICHIGAN AVE STE 700
CHICAGO IL
60601-7487
US

IV. Provider business mailing address

180 N MICHIGAN AVE STE 700
CHICAGO IL
60601-7487
US

V. Phone/Fax

Practice location:
  • Phone: 312-726-4011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number180007454
License Number StateIL

VIII. Authorized Official

Name: IRA CHASNOFF
Title or Position: PRESIDENT
Credential: MD
Phone: 312-726-4011