Provider Demographics
NPI:1437692639
Name:NEW AGE SERVICES CORPORATION
Entity Type:Organization
Organization Name:NEW AGE SERVICES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:WESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-542-1150
Mailing Address - Street 1:1330 S KOSTNER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-1152
Mailing Address - Country:US
Mailing Address - Phone:773-542-1150
Mailing Address - Fax:
Practice Address - Street 1:1330 S KOSTNER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-1152
Practice Address - Country:US
Practice Address - Phone:773-542-1150
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEW AGE SERVICES CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health