Provider Demographics
NPI:1851530406
Name:CHICAGO YOUTH CENTERS
Entity Type:Organization
Organization Name:CHICAGO YOUTH CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:J.
Authorized Official - Middle Name:HARRY
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-795-3500
Mailing Address - Street 1:104 S MICHIGAN AVE STE 1400
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-5916
Mailing Address - Country:US
Mailing Address - Phone:312-795-3500
Mailing Address - Fax:312-795-3520
Practice Address - Street 1:461 E 111TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-4558
Practice Address - Country:US
Practice Address - Phone:773-468-4660
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00418812251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL08001OtherMEDICAID CERTIFICATION
IL08001OtherMEDICAID CERTIFICATION