Provider Demographics
NPI:1417431537
Name:SERTOMA CENTRE, INC.
Entity Type:Organization
Organization Name:SERTOMA CENTRE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GUS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DEN BRINK
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:708-730-6216
Mailing Address - Street 1:4343 W 123RD ST
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-1807
Mailing Address - Country:US
Mailing Address - Phone:708-730-6216
Mailing Address - Fax:708-371-9747
Practice Address - Street 1:4331 LINCOLN HWY STE A
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-2472
Practice Address - Country:US
Practice Address - Phone:708-748-1951
Practice Address - Fax:708-748-1962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========004Medicaid