Healthcare Provider Details

I. General information

NPI: 1164388484
Provider Name (Legal Business Name): ICC TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2025
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E 111TH STREET
CHICAGO IL
60628-9998
US

IV. Provider business mailing address

1 E 111TH STREET
CHICAGO IL
60628-9998
US

V. Phone/Fax

Practice location:
  • Phone: 773-552-2769
  • Fax:
Mailing address:
  • Phone: 773-552-2769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number
License Number State

VIII. Authorized Official

Name: MR. MARVIN D COKLOW
Title or Position: COMPLIANCE OFFICER
Credential:
Phone: 773-597-7698