=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629256060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNTY OF LAKE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2008
-----------------------------------------------------
Last Update Date | 09/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24647 N MILWAUKEE AVE
-----------------------------------------------------
City | VERNON HILLS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60061-1567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-377-7835
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3010 GRAND AVE.
-----------------------------------------------------
City | WAUKEGAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60085
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ANGELA COOPER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-377-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | 002330005
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------