Provider Demographics
NPI:1609094788
Name:PARK LAWN SCHOOL & ACTIVITY CENTER, INC.
Entity Type:Organization
Organization Name:PARK LAWN SCHOOL & ACTIVITY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WEISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-425-3344
Mailing Address - Street 1:10833 LAPORTE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5412
Mailing Address - Country:US
Mailing Address - Phone:708-425-3344
Mailing Address - Fax:708-425-3530
Practice Address - Street 1:10833 LAPORTE AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5412
Practice Address - Country:US
Practice Address - Phone:708-425-3344
Practice Address - Fax:708-425-3530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILNONE251C00000X
IL0027078315P00000X
IL0035527315P00000X
IL92C173320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services
Not Answered315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Not Answered320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0027078Medicaid
IL0035527Medicaid
IL92C172OtherDHS LICENSE