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	08005	OTHER	IL	DASA

General Provider Information

NPI Number	:	1790130607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OMNI YOUTH SERVICES

Provider Business Mailing Address
First Line	:	1616 N ARLINGTON HEIGHTS RD
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60004-3981
Country	:	US
Telephone Number	:	847-353-1500
Fax Number	:	847-253-7230

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	:	847-353-1500
Fax Number	:	847-253-7230

Authorized Official
Title or Position	:	COO
Name	:	DORYCE MCCARTHY
Credential	:
Telephone Number	:	847-353-1500

Provider Enumeration Date	:	04/28/2016
Last Update Date	:	04/28/2016

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