Provider Demographics
NPI:1619077385
Name:FULL LIFE CENTERS, LLC
Entity Type:Organization
Organization Name:FULL LIFE CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:E
Authorized Official - Last Name:SIEGLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-529-1200
Mailing Address - Street 1:2750 N RACINE AVE
Mailing Address - Street 2:SUITE #1
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1206
Mailing Address - Country:US
Mailing Address - Phone:773-529-1200
Mailing Address - Fax:773-296-6131
Practice Address - Street 1:2750 N RACINE AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1206
Practice Address - Country:US
Practice Address - Phone:773-529-1200
Practice Address - Fax:773-296-6131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-23
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL336046711101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicare UPIN