Provider Demographics
NPI:1538524236
Name:SHINE ON ME INC. OF ILLINOIS
Entity type:Organization
Organization Name:SHINE ON ME INC. OF ILLINOIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-743-7011
Mailing Address - Street 1:153 NANTI ST
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2529
Mailing Address - Country:US
Mailing Address - Phone:708-506-3900
Mailing Address - Fax:
Practice Address - Street 1:153 NANTI ST
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2529
Practice Address - Country:US
Practice Address - Phone:708-506-3900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-22
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL201400008C320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL20150923983310Medicaid