Provider Demographics
NPI:1497002521
Name:ONE HOPE UNITED- NORTHERN REGION
Entity Type:Organization
Organization Name:ONE HOPE UNITED- NORTHERN REGION
Other - Org Name:CAMPUS BUILDING #7
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-949-5612
Mailing Address - Street 1:215 N MILWAUKEE AVE
Mailing Address - Street 2:P.O. BOX 1128
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-8529
Mailing Address - Country:US
Mailing Address - Phone:847-245-6500
Mailing Address - Fax:847-356-1842
Practice Address - Street 1:215 N MILWAUKEE AVE
Practice Address - Street 2:CAMPUS BUILDING #7
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046-8529
Practice Address - Country:US
Practice Address - Phone:847-245-6500
Practice Address - Fax:847-356-1842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL004019-12322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2A00IPI004Medicaid