Provider Demographics
NPI:1194228429
Name:ILLINOIS SUPREME HEALTH ORGANIZATION
Entity Type:Organization
Organization Name:ILLINOIS SUPREME HEALTH ORGANIZATION
Other - Org Name:ISHO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANJHONI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMONDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-841-5006
Mailing Address - Street 1:5305 PLEASANT LN
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-1159
Mailing Address - Country:US
Mailing Address - Phone:312-841-5006
Mailing Address - Fax:
Practice Address - Street 1:5305 PLEASANT LN
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-1159
Practice Address - Country:US
Practice Address - Phone:312-841-5006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health