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General NPI Number Information
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NPI Number | 1194228429
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Entity Type | Organization
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Legal Business Name | ILLINOIS SUPREME HEALTH ORGANIZATION
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Dates
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Enumeration Date | 03/13/2018
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Last Update Date | 03/13/2018
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Provider Practice Location Address
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Address Line | 5305 PLEASANT LN
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City | CRESTWOOD
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State | IL
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Zip | 60418-1159
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Country | US
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Telephone | 312-841-5006
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Fax |
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Provider Business Mailing Address
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Address Line | 5305 PLEASANT LN
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City | CRESTWOOD
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State | IL
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Zip | 60418-1159
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Country | US
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Telephone | 312-841-5006
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MANJHONI EDMONDSON
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Credential |
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Telephone | 312-841-5006
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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