Provider Demographics
NPI:1053531384
Name:LESTER AND ROSALIE ANIXTER CENTER
Entity type:Organization
Organization Name:LESTER AND ROSALIE ANIXTER CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DESMOND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-761-1501
Mailing Address - Street 1:6610 N. CLARK STREET
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626
Mailing Address - Country:US
Mailing Address - Phone:773-761-1501
Mailing Address - Fax:773-977-1240
Practice Address - Street 1:1727 W NORTH SHORE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-4039
Practice Address - Country:US
Practice Address - Phone:847-675-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2021-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========005Medicaid