Healthcare Provider Details

I. General information

NPI: 1629374566
Provider Name (Legal Business Name): STONYBROOK CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 E ROOSEVELT RD
WHEATON IL
60187-6806
US

IV. Provider business mailing address

1506 E ROOSEVELT RD
WHEATON IL
60187-6806
US

V. Phone/Fax

Practice location:
  • Phone: 630-221-1400
  • Fax: 630-221-1411
Mailing address:
  • Phone: 630-221-1400
  • Fax: 630-221-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberA-8645-0001-A
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License NumberA-8645-0002-A
License Number StateIL

VIII. Authorized Official

Name: CHARLES FRANCIS WALTER
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 630-221-1400