Provider Demographics
NPI:1548774961
Name:PRENTICE PLACE
Entity Type:Organization
Organization Name:PRENTICE PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PRENTICE
Authorized Official - Middle Name:
Authorized Official - Last Name:EARL
Authorized Official - Suffix:
Authorized Official - Credentials:CADC,NCRS,CAMSLL
Authorized Official - Phone:773-391-3123
Mailing Address - Street 1:1115 S PLYMOUTH CT APT 501
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2032
Mailing Address - Country:US
Mailing Address - Phone:773-391-3123
Mailing Address - Fax:312-753-3326
Practice Address - Street 1:255 W 112TH PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4132
Practice Address - Country:US
Practice Address - Phone:773-391-3123
Practice Address - Fax:773-701-6844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility