Provider Demographics
NPI:1376900571
Name:UCP SEGUIN GREATER CHICAGO
Entity Type:Organization
Organization Name:UCP SEGUIN GREATER CHICAGO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SERVICES ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-863-3803
Mailing Address - Street 1:3100 S. CENTRAL AVE.
Mailing Address - Street 2:
Mailing Address - City:CICETO
Mailing Address - State:IL
Mailing Address - Zip Code:60804
Mailing Address - Country:US
Mailing Address - Phone:708-863-3803
Mailing Address - Fax:
Practice Address - Street 1:7550 W. 183RD
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477
Practice Address - Country:US
Practice Address - Phone:708-863-3803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UCP SEGUIN GREATER CHICAGO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL#2B051P1166Medicaid