Provider Demographics
NPI:1386920221
Name:IBUKUN COMPREHENSIVE COMMUNITY SERVICES, INC.
Entity type:Organization
Organization Name:IBUKUN COMPREHENSIVE COMMUNITY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AKIWOWO
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:773-994-6125
Mailing Address - Street 1:6752 S PERRY AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-3714
Mailing Address - Country:US
Mailing Address - Phone:773-994-6125
Mailing Address - Fax:773-994-6135
Practice Address - Street 1:6752 S PERRY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-3714
Practice Address - Country:US
Practice Address - Phone:773-994-6125
Practice Address - Fax:773-994-6135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004168322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children