Provider Demographics
NPI:1619428273
Name:360 ACTIVE RECOVERY
Entity Type:Organization
Organization Name:360 ACTIVE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JULIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:HEARN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:872-203-3500
Mailing Address - Street 1:2221 W. NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647
Mailing Address - Country:US
Mailing Address - Phone:872-203-3500
Mailing Address - Fax:
Practice Address - Street 1:2221 W NORTH AVE
Practice Address - Street 2:#1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-5429
Practice Address - Country:US
Practice Address - Phone:872-203-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2487457261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service