Provider Demographics
NPI:1942651013
Name:SOLEDAD SOCIAL SERVICES CORPORATION
Entity Type:Organization
Organization Name:SOLEDAD SOCIAL SERVICES CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FUTOTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-706-9308
Mailing Address - Street 1:7107 W BELMONT AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-4500
Mailing Address - Country:US
Mailing Address - Phone:773-481-9096
Mailing Address - Fax:773-622-8385
Practice Address - Street 1:7107 W BELMONT AVE STE 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4500
Practice Address - Country:US
Practice Address - Phone:773-481-9096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL200900006C253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid