Basic Information
| Provider Information | |||||||||
| NPI: | 1366925489 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LURIE CHILDREN'S ADOLESCENT SUBSTANCE ABUSE AND PREVENTION PROGARM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 E CHICAGO AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122274000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1440 N DAYTON ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606422644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122274000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2018 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
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| AuthorizedOfficialLastName: | SWANSON | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3122277118 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ANN & ROBERT H. LURIE CHILDREN'S HOSPITAL OF CHICAGO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.