Organization
T.O.C INCOORPORATION
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. IDAYAT A UFOMBA (DIRECTOR)
(708) 710-0640
Entity
Organization
Contact information
Practice address
4709 ABBEY LN, MATTESON, IL 60443-1894
(708) 710-0640
Mailing address
4709 ABBEY LN, MATTESON, IL 60443-1894
(708) 710-0640
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
201400007C
IL
Other
Enumeration date
05/14/2015
Last updated
10/10/2016
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