Healthcare Provider Details

I. General information

NPI: 1093209264
Provider Name (Legal Business Name): LESTER & ROSALIE ANIXTER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5108 W ROSCOE ST
CHICAGO IL
60641-4204
US

IV. Provider business mailing address

6610 N CLARK ST
CHICAGO IL
60626-4062
US

V. Phone/Fax

Practice location:
  • Phone: 773-685-7541
  • Fax:
Mailing address:
  • Phone: 773-761-1501
  • Fax: 773-274-3523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARY DESMOND
Title or Position: SR. DIRECTOR OF FINANCE
Credential:
Phone: 773-761-1501