Healthcare Provider Details

I. General information

NPI: 1275647315
Provider Name (Legal Business Name): MIDWEST BRAIN INJURY CLUBHOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 N HOOKER ST #302
CHICAGO IL
60622-4549
US

IV. Provider business mailing address

1010 N HOOKER ST #302
CHICAGO IL
60622-4549
US

V. Phone/Fax

Practice location:
  • Phone: 312-932-1120
  • Fax: 312-932-1140
Mailing address:
  • Phone: 312-932-1120
  • Fax: 312-932-1140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: DEBORAH GIESLER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 312-932-1120