Healthcare Provider Details

I. General information

NPI: 1699989236
Provider Name (Legal Business Name): LESTER AND ROSALIE ANIXTER CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 01/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W CHASE AVE
CHICAGO IL
60626-2108
US

IV. Provider business mailing address

6610 N. CLARK STREET
CHICAGO IL
60626
US

V. Phone/Fax

Practice location:
  • Phone: 847-675-3200
  • Fax: 847-675-3274
Mailing address:
  • Phone: 773-761-1501
  • Fax: 773-977-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number04006
License Number StateIL

VIII. Authorized Official

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