=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942752126
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAM HOUSE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2016
-----------------------------------------------------
Last Update Date | 11/05/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 N GENESEE ST
-----------------------------------------------------
City | WAUKEGAN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60085-4005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-307-2454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1828 N MANSARD BLVD APT 2G
-----------------------------------------------------
City | GRIFFITH
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46319-1350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-307-2454
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. KEVIN MEANS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 312-307-2454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------