Provider Demographics
NPI:1669876033
Name:MIDWEST BRAIN INJURY CLUBHOUSE
Entity type:Organization
Organization Name:MIDWEST BRAIN INJURY CLUBHOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMIKO
Authorized Official - Middle Name:
Authorized Official - Last Name:BESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-226-8714
Mailing Address - Street 1:1021 W ADAMS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2936
Mailing Address - Country:US
Mailing Address - Phone:312-226-8720
Mailing Address - Fax:312-226-8722
Practice Address - Street 1:1021 W ADAMS ST.
Practice Address - Street 2:SUITE 200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2936
Practice Address - Country:US
Practice Address - Phone:312-226-8720
Practice Address - Fax:312-226-8722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-14
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No385H00000XRespite Care FacilityRespite Care