Healthcare Provider Details

I. General information

NPI: 1720516099
Provider Name (Legal Business Name): GREAT HEIGHTS OTP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1473 RING RD
CALUMET CITY IL
60409-5459
US

IV. Provider business mailing address

1473 RING RD
CALUMET CITY IL
60409-5459
US

V. Phone/Fax

Practice location:
  • Phone: 708-862-8156
  • Fax:
Mailing address:
  • Phone: 708-862-8156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: DR. ADEYEMI FATOKI
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 708-862-8156