Healthcare Provider Details

I. General information

NPI: 1710519046
Provider Name (Legal Business Name): SHAW COMMUNITY INTEGRATION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8119 S VERNON AVE
CHICAGO IL
60619-4913
US

IV. Provider business mailing address

8119 S VERNON AVE # 1
CHICAGO IL
60619-4913
US

V. Phone/Fax

Practice location:
  • Phone: 773-952-1965
  • Fax: 708-810-9792
Mailing address:
  • Phone: 773-952-1965
  • Fax: 708-810-9792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. RHONDA JEFFERSON
Title or Position: REGISTERED NURSE
Credential: RN
Phone: 773-952-1965