MEDICARE: LESTER AND ROSALIE ANIXTER CENTER

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1336693704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LESTER AND ROSALIE ANIXTER CENTER

Provider Business Mailing Address
First Line	:	6610 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60626-4062
Country	:	US
Telephone Number	:	773-761-1501
Fax Number	:	773-977-1240

Provider Business Practice Location Address
First Line	:	3405 S MICHIGAN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-3819
Country	:	US
Telephone Number	:	312-791-0035
Fax Number	:	312-791-0626

Authorized Official
Title or Position	:	CLAIMS ANALYST
Name	:	HEIDI OLKOWSKI
Credential	:
Telephone Number	:	773-697-6529

Provider Enumeration Date	:	08/15/2016
Last Update Date	:	04/28/2021

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