=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114439346
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RESTORATION CENTER CHICAGO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2017
-----------------------------------------------------
Last Update Date | 10/27/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 W 35TH ST STE 5B5220
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60609-1305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-548-9051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 W 35TH ST STE 5B5220
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60609-1305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-548-9051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | SAMANTHA LUSSIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-549-9051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------