Provider Demographics
NPI:1700100625
Name:NEW LIFE MEDCO INC
Entity Type:Organization
Organization Name:NEW LIFE MEDCO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ELWOOD
Authorized Official - Middle Name:P
Authorized Official - Last Name:NYTHER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:773-818-9607
Mailing Address - Street 1:329 W 18TH
Mailing Address - Street 2:STE 500 BOX 20
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616
Mailing Address - Country:US
Mailing Address - Phone:773-818-9607
Mailing Address - Fax:
Practice Address - Street 1:329 W 18TH ST
Practice Address - Street 2:STE 500
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619
Practice Address - Country:US
Practice Address - Phone:773-818-9607
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-22
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149004694261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)