Provider Demographics
NPI:1174779771
Name:COMPREHENSIVE HEALTH AGENCY NURTURING GUEST ENERVATION
Entity type:Organization
Organization Name:COMPREHENSIVE HEALTH AGENCY NURTURING GUEST ENERVATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:KENNER
Authorized Official - Last Name:WASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-331-2679
Mailing Address - Street 1:14719 HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-1920
Mailing Address - Country:US
Mailing Address - Phone:708-331-2679
Mailing Address - Fax:
Practice Address - Street 1:14719 HALSTED ST
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-1920
Practice Address - Country:US
Practice Address - Phone:708-331-2679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.106435163W00000X
171M00000X
IL036.109938208D00000X
IL071.006944103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty