Provider Demographics
NPI:1932318920
Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Entity Type:Organization
Organization Name:LUTHERAN SOCIAL SERVICES OF ILLINOIS
Other - Org Name:BHS KENMORE FACILITY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
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:847-390-4651
Mailing Address - Street 1:1001 E TOUHY AVE STE 50
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-5817
Mailing Address - Country:US
Mailing Address - Phone:847-635-4600
Mailing Address - Fax:847-297-3407
Practice Address - Street 1:5517 N KENMORE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-1515
Practice Address - Country:US
Practice Address - Phone:773-275-7962
Practice Address - Fax:773-275-0728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0286-0009-A261QR0405X
ILA-0286-0011-A324500000X
ILA-0286-0008-A324500000X
ILA-0286-0012-A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========033Medicaid