Healthcare Provider Details

I. General information

NPI: 1053772020
Provider Name (Legal Business Name): FRONTIER HEALTHCARE SYSTEMS OF ILLINOIS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20280 GOVERNORS HWY STE 102
OLYMPIA FIELDS IL
60461-1068
US

IV. Provider business mailing address

900 OGDEN AVE # 335
DOWNERS GROVE IL
60515-2829
US

V. Phone/Fax

Practice location:
  • Phone: 708-234-0388
  • Fax: 708-234-0394
Mailing address:
  • Phone: 708-234-0388
  • Fax: 708-234-0394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LETASHA LEWIS
Title or Position: OWNER
Credential: APN
Phone: 901-283-4011