Provider Demographics
NPI:1033347794
Name:SOUTHWEST DISABILITIES SERVICES & SUPPORT NFP
Entity Type:Organization
Organization Name:SOUTHWEST DISABILITIES SERVICES & SUPPORT NFP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:708-753-1670
Mailing Address - Street 1:286 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-3730
Mailing Address - Country:US
Mailing Address - Phone:708-753-1670
Mailing Address - Fax:708-753-1679
Practice Address - Street 1:286 E 16TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60411-3730
Practice Address - Country:US
Practice Address - Phone:708-753-1670
Practice Address - Fax:708-753-1679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid