Provider Demographics
NPI:1922277631
Name:BEN GORDON CENTER
Entity Type:Organization
Organization Name:BEN GORDON CENTER
Other - Org Name:DASA MEDICAID PROVIDER
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-756-4875
Mailing Address - Street 1:12 HEALTH SERVICES DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9637
Mailing Address - Country:US
Mailing Address - Phone:815-756-4875
Mailing Address - Fax:815-756-2944
Practice Address - Street 1:12 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9637
Practice Address - Country:US
Practice Address - Phone:815-756-4875
Practice Address - Fax:815-756-2944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEN GORDON CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA0254001A251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========002Medicaid