Provider Demographics
NPI:1619129715
Name:ASSOCIATION FOR INDIVIDUAL DEVELOPMENT
Entity Type:Organization
Organization Name:ASSOCIATION FOR INDIVIDUAL DEVELOPMENT
Other - Org Name:AID- TAC HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:O'SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-966-4001
Mailing Address - Street 1:309 W. NEW INDIAN TRAIL COURT
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-2494
Mailing Address - Country:US
Mailing Address - Phone:630-966-4168
Mailing Address - Fax:630-844-2065
Practice Address - Street 1:421 N CONSTITUTION DR
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3209
Practice Address - Country:US
Practice Address - Phone:630-859-7650
Practice Address - Fax:630-859-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0034108315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL726880Medicare PIN