Healthcare Provider Details

I. General information

NPI: 1972374528
Provider Name (Legal Business Name): LOCAL WORX COMMUNITY SPACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2024
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22239 WILLOW TREE AVE
SAUK VILLAGE IL
60411-5159
US

IV. Provider business mailing address

9923 RIDGELAND AVE # 118
CHICAGO RIDGE IL
60415-1262
US

V. Phone/Fax

Practice location:
  • Phone: 331-207-0188
  • Fax:
Mailing address:
  • Phone: 331-207-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DAREON WOODARD
Title or Position: VICE PRESIDENT
Credential:
Phone: 331-207-0188