Healthcare Provider Details

I. General information

NPI: 1316151871
Provider Name (Legal Business Name): PDSSC-CHICAGO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 N ELSTON AVE
CHICAGO IL
60614
US

IV. Provider business mailing address

2260 N ELSTON AVE
CHICAGO IL
60614-2930
US

V. Phone/Fax

Practice location:
  • Phone: 773-772-2450
  • Fax:
Mailing address:
  • Phone: 773-772-2450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberA-3407-0001-A
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License NumberA-3407-0001-A
License Number StateIL

VIII. Authorized Official

Name: DR. KENNETH P DAVIS
Title or Position: PRESIDENT
Credential: MD, PH.D
Phone: 773-772-2450