Provider Demographics
NPI:1154141141
Name:ALCORN CLINICAL
Entity type:Organization
Organization Name:ALCORN CLINICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:ALCORN
Authorized Official - Suffix:IV
Authorized Official - Credentials:PSYD
Authorized Official - Phone:708-243-2894
Mailing Address - Street 1:715 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-3821
Mailing Address - Country:US
Mailing Address - Phone:708-243-2894
Mailing Address - Fax:
Practice Address - Street 1:637 LAKE RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-4249
Practice Address - Country:US
Practice Address - Phone:708-243-2894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-14
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)