MEDICARE: LEEDA SERVICES OF ILLINOIS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	400477	IL

General Provider Information

NPI Number	:	1194990002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEEDA SERVICES OF ILLINOIS, INC.

Provider Business Mailing Address
First Line	:	1607 W HOWARD ST UNIT 400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-1675
Country	:	US
Telephone Number	:	773-274-9760
Fax Number	:

Provider Business Practice Location Address
First Line	:	1607 W HOWARD ST UNIT 400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-1675
Country	:	US
Telephone Number	:	773-274-9760
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EDWARD C. ANDERSON
Credential	:
Telephone Number	:	773-274-9760

Provider Enumeration Date	:	04/23/2008
Last Update Date	:	04/23/2008

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