Provider Demographics
NPI:1922383314
Name:GARDEN OF PARYER YOUTH CENTER
Entity Type:Organization
Organization Name:GARDEN OF PARYER YOUTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-933-2493
Mailing Address - Street 1:657 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-4055
Mailing Address - Country:US
Mailing Address - Phone:815-933-2493
Mailing Address - Fax:815-933-2494
Practice Address - Street 1:657 E COURT ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-4055
Practice Address - Country:US
Practice Address - Phone:815-933-2493
Practice Address - Fax:815-933-2494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-129-294251V00000X
IL180-006-235251V00000X
IL180-0007-145251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable