MEDICARE: OMNI YOUTH SERVICES

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	08005	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205076858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI YOUTH SERVICES

Provider Business Mailing Address
First Line	:	1111 W LAKE COOK RD
Second Line	:
City	:	BUFFALO GROVE
State	:	IL
Zip	:	60089-1926
Country	:	US
Telephone Number	:	847-353-1500
Fax Number	:	847-465-1964

Provider Business Practice Location Address
First Line	:	1616 N ARLINGTON HEIGHTS RD
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-3981
Country	:	US
Telephone Number	:	847-253-6010
Fax Number	:	847-253-7230

Authorized Official
Title or Position	:	CFO
Name	:	MR. SHANAN EGGER
Credential	:
Telephone Number	:	847-353-1762

Provider Enumeration Date	:	02/23/2009
Last Update Date	:	02/23/2009

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