Provider Demographics
NPI:1285188342
Name:COVENANT ENABLING RESIDENCES OF ILLINOIS
Entity Type:Organization
Organization Name:COVENANT ENABLING RESIDENCES OF ILLINOIS
Other - Org Name:BJORKLUND HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-687-2038
Mailing Address - Street 1:15841 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2911
Mailing Address - Country:US
Mailing Address - Phone:708-687-2038
Mailing Address - Fax:708-687-2762
Practice Address - Street 1:15841 TERRACE DR
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-2911
Practice Address - Country:US
Practice Address - Phone:708-687-2038
Practice Address - Fax:708-687-2762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities