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General NPI Number Information
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NPI Number | 1891296802
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Entity Type | Organization
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Legal Business Name | THE IDS GROUP CHICAGO
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Dates
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Enumeration Date | 02/25/2018
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Last Update Date | 02/25/2018
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Provider Practice Location Address
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Address Line | 1117 N ASHLAND AVE
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City | CHICAGO
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State | IL
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Zip | 60622-3986
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Country | US
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Telephone | 312-263-1131
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Fax |
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Provider Business Mailing Address
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Address Line | 5161 S LAPORTE AVE # 1N
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City | CHICAGO
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State | IL
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Zip | 60638-3060
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Country | US
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Telephone | 708-935-1821
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LATECHIA HESTER
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Credential | LPC, CADC
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Telephone | 312-263-1131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | A-2779-0001-A
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License Number State | IL
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