Healthcare Provider Details

I. General information

NPI: 1750883286
Provider Name (Legal Business Name): BUENA VISTA GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 DIXIE HWY
CHICAGO HEIGHTS IL
60411-1739
US

IV. Provider business mailing address

3740 N LAKE SHORE DR APT 8A
CHICAGO IL
60613-4201
US

V. Phone/Fax

Practice location:
  • Phone: 708-481-4200
  • Fax: 708-481-3302
Mailing address:
  • Phone: 708-481-4200
  • Fax: 708-481-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number StateIL

VIII. Authorized Official

Name: DR. WILLIAM EVANS
Title or Position: MD/OWNER
Credential: MD
Phone: 708-481-4200