Healthcare Provider Details

I. General information

NPI: 1740516640
Provider Name (Legal Business Name): JANASTON MANAGEMENT & DEVELOPMENT CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2009
Last Update Date: 10/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4942 W DIVISION ST
CHICAGO IL
60651-3158
US

IV. Provider business mailing address

4942 W DIVISION ST
CHICAGO IL
60651-3158
US

V. Phone/Fax

Practice location:
  • Phone: 773-261-0075
  • Fax: 773-261-0084
Mailing address:
  • Phone: 773-261-0075
  • Fax: 773-261-0084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberYESU
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number946213
License Number StateIL

VIII. Authorized Official

Name: DR. ROLAND EDWARD WESLEY
Title or Position: CEO
Credential: PH.D
Phone: 773-261-0075