Healthcare Provider Details

I. General information

NPI: 1881139418
Provider Name (Legal Business Name): GREAT HEIGHTS OTP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E MCKINLEY RD
OTTAWA IL
61350-4805
US

IV. Provider business mailing address

315 E MCKINLEY RD
OTTAWA IL
61350-4805
US

V. Phone/Fax

Practice location:
  • Phone: 815-434-0228
  • Fax:
Mailing address:
  • Phone: 815-434-0228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State

VIII. Authorized Official

Name: ADEYEMI FATOKI
Title or Position: OWNER
Credential: MD
Phone: 312-952-9378