Provider Demographics
NPI:1417134131
Name:BOYS & GIRLS CLUB OF CHICAGO - ROBERT R. MCCORMICK BOYS & GIRLS CLUB
Entity Type:Organization
Organization Name:BOYS & GIRLS CLUB OF CHICAGO - ROBERT R. MCCORMICK BOYS & GIRLS CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLUB DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-271-8400
Mailing Address - Street 1:4835 N SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-3718
Mailing Address - Country:US
Mailing Address - Phone:773-271-8400
Mailing Address - Fax:773-271-2425
Practice Address - Street 1:4835 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-3718
Practice Address - Country:US
Practice Address - Phone:773-271-8400
Practice Address - Fax:773-271-2425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty