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Organization
PLACE OF RESTORATION
Active
Organization
PLACE OF RESTORATION
Active
Parent organization
THE LORD'S TABLE
Other names
THE LORD'S TABLE
Organization subpart
Yes
Provider details
NPI number
Legal business name
THE LORD'S TABLE
Authorized official
MR. OLUMIDE OLUWOLE RN (DIRECTOR)
(773) 392-1585
Entity
Organization
Contact information
Practice address
4332 N KEDZIE AVE, 1ST FLOOR, CHICAGO, IL 60618-1302
(773) 267-5008
Mailing address
4332 N KEDZIE AVE, 1ST FLOOR, CHICAGO, IL 60618-1302
(773) 267-5008
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Enumeration date
09/24/2009
Last updated
09/24/2009
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