Healthcare Provider Details

I. General information

NPI: 1174926869
Provider Name (Legal Business Name): LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 AVENUE OF THE CITIES SUITE 102
MOLINE IL
61265-4454
US

IV. Provider business mailing address

1001 E TOUHY AVE SUITE 300
DES PLAINES IL
60018-5801
US

V. Phone/Fax

Practice location:
  • Phone: 309-797-0200
  • Fax: 309-797-5135
Mailing address:
  • Phone: 847-635-4600
  • Fax: 847-699-5117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number3000753
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK STUTRUD
Title or Position: CEO
Credential:
Phone: 847-635-4600