Provider Demographics
NPI:1619329604
Name:KWANZA SUITES CORPORATION
Entity Type:Organization
Organization Name:KWANZA SUITES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:ADDISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-814-1123
Mailing Address - Street 1:9652 S FRANCISCO AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9652 S FRANCISCO AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2710
Practice Address - Country:US
Practice Address - Phone:708-425-0193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities