Provider Demographics
NPI:1629721816
Name:KILPATRICK RENAISSANCE
Entity Type:Organization
Organization Name:KILPATRICK RENAISSANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BANGHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-645-8900
Mailing Address - Street 1:2501 W WASHINGTON BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4655 W BERTEAU AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2647
Practice Address - Country:US
Practice Address - Phone:773-645-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RENAISSANCE SOCIAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management