Provider Demographics
NPI:1336608439
Name:COLUMBUS MANOR
Entity Type:Organization
Organization Name:COLUMBUS MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BECKETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-341-6707
Mailing Address - Street 1:1609 SIBLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2217
Mailing Address - Country:US
Mailing Address - Phone:708-862-4054
Mailing Address - Fax:708-862-4138
Practice Address - Street 1:5107 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-4316
Practice Address - Country:US
Practice Address - Phone:708-862-4054
Practice Address - Fax:708-862-4138
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CALUMET COUNSELING AND DUI SERVICES,INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty