Healthcare Provider Details

I. General information

NPI: 1598278749
Provider Name (Legal Business Name): ELEMENTAL TREATMENT CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 S WESTERN AVE APT 1
CHICAGO IL
60612-4682
US

IV. Provider business mailing address

612 S WESTERN AVE APT 1
CHICAGO IL
60612-4682
US

V. Phone/Fax

Practice location:
  • Phone: 331-330-9955
  • Fax:
Mailing address:
  • Phone: 331-330-9955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MARTINS A ADEOYE
Title or Position: CEO
Credential: MD
Phone: 331-330-9955