Provider Demographics
NPI:1407125156
Name:INTERNATIONAL PENTECOSTAL ASSY. ECUM. (IPAE)
Entity Type:Organization
Organization Name:INTERNATIONAL PENTECOSTAL ASSY. ECUM. (IPAE)
Other - Org Name:BROTHERS KEEPER COMMUNITY RESOURCE CENTER (CRC)
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOY
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:708-758-1840
Mailing Address - Street 1:283 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-2837
Mailing Address - Country:US
Mailing Address - Phone:708-758-1840
Mailing Address - Fax:708-758-1845
Practice Address - Street 1:1311 E STEGER RD
Practice Address - Street 2:
Practice Address - City:STEGER
Practice Address - State:IL
Practice Address - Zip Code:60475-6017
Practice Address - Country:US
Practice Address - Phone:855-358-5353
Practice Address - Fax:708-758-1845
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BROTHERS KEEPER COMMUNITY RESOURCE CENTER (CRC)
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
ILDCN:005115251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management