MEDICARE: KILPATRICK RENAISSANCE

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	251B00000X	Case Management Agency
2	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1629721816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KILPATRICK RENAISSANCE

Provider Business Mailing Address
First Line	:	2501 W WASHINGTON BLVD STE 401
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-2127
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4655 W BERTEAU AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60641-2647
Country	:	US
Telephone Number	:	773-645-8900
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MICHAEL BANGHART
Credential	:
Telephone Number	:	773-645-8900

Provider Enumeration Date	:	01/28/2022
Last Update Date	:	01/28/2022

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