Provider Demographics
NPI:1013515501
Name:AV360 LLC
Entity Type:Organization
Organization Name:AV360 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-520-0390
Mailing Address - Street 1:2140 LAKE COOK RD
Mailing Address - Street 2:
Mailing Address - City:ALGONQUIN
Mailing Address - State:IL
Mailing Address - Zip Code:60102-5447
Mailing Address - Country:US
Mailing Address - Phone:224-333-0948
Mailing Address - Fax:
Practice Address - Street 1:2140 LAKE COOK RD
Practice Address - Street 2:
Practice Address - City:ALGONQUIN
Practice Address - State:IL
Practice Address - Zip Code:60102-5447
Practice Address - Country:US
Practice Address - Phone:224-333-0948
Practice Address - Fax:224-228-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-15
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty