Healthcare Provider Details

I. General information

NPI: 1457573099
Provider Name (Legal Business Name): NICASA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31979 N FISH LKAE RD
ROUND LAKE IL
60073
US

IV. Provider business mailing address

31979 N FISH LKAE RD
ROUND LAKE IL
60073
US

V. Phone/Fax

Practice location:
  • Phone: 847-546-6450
  • Fax: 847-546-6760
Mailing address:
  • Phone: 847-546-6450
  • Fax: 847-546-6760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberCA06140005A
License Number StateIL

VIII. Authorized Official

Name: MR. BRUCE JOHNSON
Title or Position: COO
Credential:
Phone: 847-546-6450