Provider Demographics
NPI:1538508601
Name:CAMBODIAN ASSOCIATION OF ILLINOIS
Entity Type:Organization
Organization Name:CAMBODIAN ASSOCIATION OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KOMPHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SETH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-7090
Mailing Address - Street 1:2831 W LAWRENCE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3619
Mailing Address - Country:US
Mailing Address - Phone:773-878-7090
Mailing Address - Fax:773-878-5299
Practice Address - Street 1:2831 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3619
Practice Address - Country:US
Practice Address - Phone:773-878-7090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-21
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILINH1012030253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILINH1012030Medicaid