Healthcare Provider Details

I. General information

NPI: 1316296007
Provider Name (Legal Business Name): SUNDANCE METHADONE TREATMENT CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 11/16/2021
Certification Date: 11/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 N BROADWAY ST 3RD FLOOR
CHICAGO IL
60640-5975
US

IV. Provider business mailing address

4545 N BROADWAY ST 3RD FLOOR
CHICAGO IL
60640-5975
US

V. Phone/Fax

Practice location:
  • Phone: 773-784-1111
  • Fax: 773-784-4910
Mailing address:
  • Phone: 773-784-1111
  • Fax: 773-784-4910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberA31350001
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberA31350001
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License NumberA31350001
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberA31350001
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: MR. TONY P WOODARD
Title or Position: PROGRAM DIRECTOR
Credential: MA/CADC
Phone: 773-769-4545