Provider Demographics
NPI:1366733529
Name:AWAKENED ALTERNATIVES ENTERPRISES
Entity type:Organization
Organization Name:AWAKENED ALTERNATIVES ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-748-1520
Mailing Address - Street 1:3235 VOLLMER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FLOSSMOOR
Mailing Address - State:IL
Mailing Address - Zip Code:60422-2013
Mailing Address - Country:US
Mailing Address - Phone:708-748-1520
Mailing Address - Fax:708-748-1790
Practice Address - Street 1:3235 VOLLMER RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FLOSSMOOR
Practice Address - State:IL
Practice Address - Zip Code:60422-2013
Practice Address - Country:US
Practice Address - Phone:708-748-1520
Practice Address - Fax:708-748-1790
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AWAKENED ALTERNATIVES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid