Healthcare Provider Details

I. General information

NPI: 1932673449
Provider Name (Legal Business Name): LESTER & ROSALIE ANIXTER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 N CENTRAL AVE
CHICAGO IL
60639-1316
US

IV. Provider business mailing address

6610 N CLARK ST
CHICAGO IL
60626-4062
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HEIDI OLKOWSKI
Title or Position: CLAIMS SPECIALIST
Credential:
Phone: 773-761-1501