1316296007 NPI number — SUNDANCE METHADONE TREATMENT CENTER,LLC

Table of content: (NPI 1316296007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316296007 NPI number — SUNDANCE METHADONE TREATMENT CENTER,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNDANCE METHADONE TREATMENT CENTER,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316296007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4545 N BROADWAY ST
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60640-5975
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-784-1111
Provider Business Mailing Address Fax Number:
773-784-4910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4545 N BROADWAY ST
Provider Second Line Business Practice Location Address:
3RD FLOOR
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60640-5975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-784-1111
Provider Business Practice Location Address Fax Number:
773-784-4910
Provider Enumeration Date:
09/10/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WOODARD
Authorized Official First Name:
TONY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
773-769-4545

Provider Taxonomy Codes

  • Taxonomy code: 261QM2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0400X , with the licence number: A31350001 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0405X , with the licence number: A31350001 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 276400000X , with the licence number: A31350001 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 324500000X , with the licence number: A31350001 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)