Provider Demographics
NPI:1386858025
Name:LESTER AND ROSALIE ANIXTER CENTER
Entity Type:Organization
Organization Name:LESTER AND ROSALIE ANIXTER CENTER
Other - Org Name:ANIXTER CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-761-1501
Mailing Address - Street 1:6610 N. CLARK STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626
Mailing Address - Country:US
Mailing Address - Phone:773-761-1501
Mailing Address - Fax:773-977-1240
Practice Address - Street 1:6610 N. CLARK STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626
Practice Address - Country:US
Practice Address - Phone:773-761-1501
Practice Address - Fax:773-977-1240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========801Medicaid