Healthcare Provider Details

I. General information

NPI: 1891065025
Provider Name (Legal Business Name): GOLD COAST CLINICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2012
Last Update Date: 01/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N MICHIGAN AVE SUITE 917W
CHICAGO IL
60611-2252
US

IV. Provider business mailing address

845 N MICHIGAN AVE SUITE 917W
CHICAGO IL
60611-2252
US

V. Phone/Fax

Practice location:
  • Phone: 312-291-8063
  • Fax: 312-291-8369
Mailing address:
  • Phone: 312-291-8063
  • Fax: 312-291-8369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number036098130
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number036098130
License Number StateIL

VIII. Authorized Official

Name: DR. BABATUNDE GBOLADE OKULEYE
Title or Position: PRESIDENT
Credential: M.D, MBA
Phone: 773-350-0020