Healthcare Provider Details

I. General information

NPI: 1386940815
Provider Name (Legal Business Name): THE RENAISSANCE CENTER I
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1337 S INDIANA PKWY
CHICAGO IL
60605-2619
US

IV. Provider business mailing address

430 E 162ND ST SUITE 492
SOUTH HOLLAND IL
60473-2258
US

V. Phone/Fax

Practice location:
  • Phone: 773-671-0466
  • Fax: 312-945-3750
Mailing address:
  • Phone: 773-671-0466
  • Fax: 312-945-3750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL
# 9
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL
# 10
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateNULL
# 11
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number StateNULL
# 12
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 13
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL
# 14
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNULL
# 15
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JERRY L WEEMS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PSY.D.
Phone: 773-671-0466