Healthcare Provider Details

I. General information

NPI: 1356385199
Provider Name (Legal Business Name): UCAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10046 S. WESTERN AVE.
CHICAGO IL
60643
US

IV. Provider business mailing address

3605 W. FILLMORE
CHICAGO IL
60624-4301
US

V. Phone/Fax

Practice location:
  • Phone: 773-588-0180
  • Fax:
Mailing address:
  • Phone: 773-588-0180
  • Fax: 773-826-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JONATHAN STACY
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 773-588-0180