Healthcare Provider Details

I. General information

NPI: 1750219416
Provider Name (Legal Business Name): ST NICHOLAS CILA HOMES CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6204 OLD PLANK BLVD
MATTESON IL
60443-1453
US

IV. Provider business mailing address

8734 CARLISLE CT
DARIEN IL
60561-5372
US

V. Phone/Fax

Practice location:
  • Phone: 773-240-9225
  • Fax: 773-240-9225
Mailing address:
  • Phone: 773-240-9225
  • Fax: 773-240-9225

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 State

VIII. Authorized Official

Name: NICHOLAS EFOSA AGBONIFO
Title or Position: PRESIDENT
Credential:
Phone: 773-240-9225