Provider Demographics
NPI:1043450562
Name:OMNI YOUTH SERVICES
Entity Type:Organization
Organization Name:OMNI YOUTH SERVICES
Other - Org Name:OMNI YOUTH SERVICES-ELA
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHANAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EGGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-353-1762
Mailing Address - Street 1:1111 W LAKE COOK RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1926
Mailing Address - Country:US
Mailing Address - Phone:847-353-1500
Mailing Address - Fax:847-465-1964
Practice Address - Street 1:1025 OLD MCHENRY RD
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-8428
Practice Address - Country:US
Practice Address - Phone:847-540-0680
Practice Address - Fax:847-540-1427
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OMNI YOUTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-24
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL08005251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08005Medicaid