Healthcare Provider Details

I. General information

NPI: 1578187886
Provider Name (Legal Business Name): SILVER GLEN ROAD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2020
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41W400 SILVER GLEN RD
ST CHARLES IL
60175-8453
US

IV. Provider business mailing address

2201 RENAISSANCE BLVD FL 3
KING OF PRUSSIA PA
19406-2709
US

V. Phone/Fax

Practice location:
  • Phone: 331-901-4225
  • Fax:
Mailing address:
  • Phone: 610-994-2900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: SERGIO CRUZ
Title or Position: CFO
Credential:
Phone: 610-427-9434