Provider Demographics
NPI:1528713013
Name:ALLEN, ANDRE LASHAWN (CEO)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:LASHAWN
Last Name:ALLEN
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20280 GOVERNORS HWY STE 206
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1068
Mailing Address - Country:US
Mailing Address - Phone:708-898-0635
Mailing Address - Fax:
Practice Address - Street 1:20280 GOVERNORS HWY STE 206
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1068
Practice Address - Country:US
Practice Address - Phone:708-898-0635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3129197649Medicaid