Healthcare Provider Details

I. General information

NPI: 1023820040
Provider Name (Legal Business Name): DOLORES & LILLIE'S PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2025
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16252 PRINCE DR
SOUTH HOLLAND IL
60473-3233
US

IV. Provider business mailing address

14 W SUPERIOR ST APT 1707
CHICAGO IL
60654-3706
US

V. Phone/Fax

Practice location:
  • Phone: 847-220-6098
  • Fax:
Mailing address:
  • Phone: 651-278-4230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIKKA TAYLOR
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 651-278-4230