Provider Demographics
NPI:1609222652
Name:KELLY ACCURATE DUI TREATMENT SERVICES, LLC
Entity Type:Organization
Organization Name:KELLY ACCURATE DUI TREATMENT SERVICES, LLC
Other - Org Name:KELLY ACCURATE DUI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER /DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:PATRICE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:CADC
Authorized Official - Phone:708-323-8270
Mailing Address - Street 1:20550 S LAGRANGE RD
Mailing Address - Street 2:LOWER LEVEL
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-1397
Mailing Address - Country:US
Mailing Address - Phone:815-630-8828
Mailing Address - Fax:
Practice Address - Street 1:20550 S LAGRANGE RD
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-1397
Practice Address - Country:US
Practice Address - Phone:815-630-8828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL341642079001Medicaid
ILA5452002AOtherCADC CERTIFICATION LICENSE NUMBER