Healthcare Provider Details

I. General information

NPI: 1740344027
Provider Name (Legal Business Name): GRAND PRAIRIE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19707 TERRACE AVE
LYNWOOD IL
60411-1335
US

IV. Provider business mailing address

17746 OAK PARK AVE
TINLEY PARK IL
60477-3936
US

V. Phone/Fax

Practice location:
  • Phone: 708-895-8057
  • Fax:
Mailing address:
  • Phone: 708-444-1012
  • Fax: 708-614-9449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DENNIS REGNIER
Title or Position: PRESIDENT & CHIEF EXECUTIVE OFFICER
Credential:
Phone: 708-623-1501