Provider Demographics
NPI:1679819734
Name:LIFECORE REHAB AND COUNSELING SERVICES SC
Entity Type:Organization
Organization Name:LIFECORE REHAB AND COUNSELING SERVICES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ASIM
Authorized Official - Middle Name:
Authorized Official - Last Name:FAROOQI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-342-7076
Mailing Address - Street 1:8051 186TH ST
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-9341
Mailing Address - Country:US
Mailing Address - Phone:708-342-7076
Mailing Address - Fax:708-342-7083
Practice Address - Street 1:16410 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452
Practice Address - Country:US
Practice Address - Phone:708-960-4023
Practice Address - Fax:708-991-7275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036131268261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)