Basic Information
| Provider Information | |||||||||
| NPI: | 1376895532 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KENNETH YOUNG CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KENNETH YOUNG CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 ROHLWING | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475248800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1001 ROHLWING RD | ||||||||
| Address2: | |||||||||
| City: | ELK GROVE VILLAGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600073217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475248800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2012 | ||||||||
| LastUpdateDate: | 10/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | BRUSKI | ||||||||
| AuthorizedOfficialFirstName: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8475248800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | Y | Managed Care Organizations | Point of Service |
No ID Information.