Provider Demographics
NPI:1588810550
Name:PROVISO FAMILY SERVICES
Entity Type:Organization
Organization Name:PROVISO FAMILY SERVICES
Other - Org Name:RESURRECTION BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER, GENERAL ACCOUNTING
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAMISKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-338-3806
Mailing Address - Street 1:1820 S 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-2864
Mailing Address - Country:US
Mailing Address - Phone:708-338-3806
Mailing Address - Fax:708-681-1289
Practice Address - Street 1:100 N RIVER RD
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1209
Practice Address - Country:US
Practice Address - Phone:708-338-3806
Practice Address - Fax:708-681-1289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1616027OtherBCBS
IL619911Medicare PIN
IL1616027OtherBCBS
IL619910Medicare PIN