MEDICARE: A NEW AGE HUMAN SERVICES CORP.

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	201500008C	IL

General Provider Information

NPI Number	:	1730623786
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A NEW AGE HUMAN SERVICES CORP.

Provider Business Mailing Address
First Line	:	5328 W PARKER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1521
Country	:	US
Telephone Number	:	773-237-8793
Fax Number	:	708-575-5903

Provider Business Practice Location Address
First Line	:	5328 W PARKER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-1521
Country	:	US
Telephone Number	:	773-237-8793
Fax Number	:	708-575-5903

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR/QIDP/RN
Name	:	CHARISSA MUNOZ-LIGO
Credential	:
Telephone Number	:	773-491-1480

Provider Enumeration Date	:	12/10/2016
Last Update Date	:	12/10/2016

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