Provider Demographics
NPI:1790225050
Name:IT'S ABOUT CHANGE SOBER LIVING, INC.
Entity Type:Organization
Organization Name:IT'S ABOUT CHANGE SOBER LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:SR
Authorized Official - Credentials:NCRS
Authorized Official - Phone:708-772-5014
Mailing Address - Street 1:394 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2107
Mailing Address - Country:US
Mailing Address - Phone:708-868-5014
Mailing Address - Fax:708-868-8335
Practice Address - Street 1:995 BODE RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-4523
Practice Address - Country:US
Practice Address - Phone:224-238-3279
Practice Address - Fax:224-238-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-8723-0002-A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC/A-8723-0002-AMedicaid