Provider Demographics
NPI:1073023149
Name:NEW AGE SERVICES CORPORATION
Entity Type:Organization
Organization Name:NEW AGE SERVICES CORPORATION
Other - Org Name:NEW AGE SERVICES CORPORATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PATIENT REVENUE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ULYSSES
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:773-542-1150
Mailing Address - Street 1:386 N YORK ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2363
Mailing Address - Country:US
Mailing Address - Phone:630-501-1742
Mailing Address - Fax:773-542-1175
Practice Address - Street 1:386 N YORK ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2363
Practice Address - Country:US
Practice Address - Phone:630-501-1742
Practice Address - Fax:773-542-1175
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW AGE SERVICES CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-03
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0579-0001-A101YA0400X, 101YP2500X, 207QA0401X, 261QR0405X
IL16008103T00000X, 104100000X, 1041C0700X, 251S00000X, 261QM0801X
261QM2800X
IL276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL333304755-60623-01Medicaid