Provider Demographics
NPI:1326720145
Name:HOUSE OF HEARTS CILA LLC
Entity Type:Organization
Organization Name:HOUSE OF HEARTS CILA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:COKLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-597-7698
Mailing Address - Street 1:2111 121ST ST
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-1201
Mailing Address - Country:US
Mailing Address - Phone:773-597-7698
Mailing Address - Fax:
Practice Address - Street 1:2111 121ST ST
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-1201
Practice Address - Country:US
Practice Address - Phone:773-597-7698
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-02
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health