MEDICARE: ELITE HOUSES OF SOBER LIVING,INC.

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	261QA3000X	Augmentative Communication Clinic/Center	A-4780-0005-A	IL
2	261QM0850X	Adult Mental Health Clinic/Center	A-4780-0005-A	IL
3	251S00000X	Community/Behavioral Health Agency	A-4780-00055-A	IL

General Provider Information

NPI Number	:	1972752392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELITE HOUSES OF SOBER LIVING,INC.

Provider Business Mailing Address
First Line	:	395 W LINCOLN HWY
Second Line	:	PO. BOX 2122
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-2442
Country	:	US
Telephone Number	:	708-755-5117
Fax Number	:	708-755-5404

Provider Business Practice Location Address
First Line	:	395 W LINCOLN HWY
Second Line	:
City	:	CHICAGO HEIGHTS
State	:	IL
Zip	:	60411-2442
Country	:	US
Telephone Number	:	708-755-5117
Fax Number	:	708-755-5404

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. ALBERT ELLIS III
Credential	:	CADC; NCRS;MISA 1
Telephone Number	:	312-515-3092

Provider Enumeration Date	:	09/10/2008
Last Update Date	:	09/10/2008

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