Provider Demographics
NPI:1881098085
Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity type:Organization
Organization Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:STUTRUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-635-4600
Mailing Address - Street 1:1001 E TOUHY AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-5801
Mailing Address - Country:US
Mailing Address - Phone:847-635-4600
Mailing Address - Fax:847-699-5117
Practice Address - Street 1:3000 W ROHMANN AVE
Practice Address - Street 2:
Practice Address - City:WEST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-4842
Practice Address - Country:US
Practice Address - Phone:309-671-0308
Practice Address - Fax:309-671-0503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-17
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL3000541253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========924Medicaid