MEDICARE: THE IDS GROUP CHICAGO

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	324500000X	Substance Abuse Rehabilitation Facility	A-2779-0001-A	IL

General Provider Information

NPI Number	:	1891296802
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE IDS GROUP CHICAGO

Provider Business Mailing Address
First Line	:	5161 S LAPORTE AVE # 1N
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60638-3060
Country	:	US
Telephone Number	:	708-935-1821
Fax Number	:

Provider Business Practice Location Address
First Line	:	1117 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-3986
Country	:	US
Telephone Number	:	312-263-1131
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LATECHIA HESTER
Credential	:	LPC, CADC
Telephone Number	:	312-263-1131

Provider Enumeration Date	:	02/25/2018
Last Update Date	:	02/25/2018

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