=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386920221
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IBUKUN COMPREHENSIVE COMMUNITY SERVICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2011
-----------------------------------------------------
Last Update Date | 10/24/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6752 S PERRY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60621-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-994-6125
-----------------------------------------------------
Fax | 773-994-6135
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6752 S PERRY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60621-3714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-994-6125
-----------------------------------------------------
Fax | 773-994-6135
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. CHRISTIAN AKIWOWO
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 773-994-6125
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 322D00000X
-----------------------------------------------------
Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
-----------------------------------------------------
License Number | 180004168
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------