Healthcare Provider Details

I. General information

NPI: 1902775257
Provider Name (Legal Business Name): LILY OF THE VALLEY SUPPORT ACADEMY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14302 S LA SALLE ST
RIVERDALE IL
60827-2743
US

IV. Provider business mailing address

14302 S LA SALLE ST
RIVERDALE IL
60827-2743
US

V. Phone/Fax

Practice location:
  • Phone: 773-757-3101
  • Fax:
Mailing address:
  • Phone: 773-757-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. DIAMOND HINES
Title or Position: CEO
Credential: LPN/ DON
Phone: 773-757-3101