Healthcare Provider Details

I. General information

NPI: 1508492745
Provider Name (Legal Business Name): OAK BROOK CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 W 22ND ST STE 29
OAK BROOK IL
60523-4625
US

IV. Provider business mailing address

2605 W 22ND ST STE 29
OAK BROOK IL
60523-4625
US

V. Phone/Fax

Practice location:
  • Phone: 630-819-8100
  • Fax: 630-568-3362
Mailing address:
  • Phone: 630-819-8100
  • Fax: 630-568-3362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JIM P WEISS
Title or Position: DIRECTOR OF QUALITY MANAGEMENT
Credential:
Phone: 402-339-1436