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General NPI Number Information
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NPI Number | 1124579073
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Entity Type | Organization
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Legal Business Name | UPTOWN DUI SERVICES
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Dates
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Enumeration Date | 10/16/2016
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Last Update Date | 10/16/2016
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Provider Practice Location Address
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Address Line | 1525 E 53RD ST STE 411
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City | CHICAGO
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State | IL
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Zip | 60615-4530
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Country | US
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Telephone | 312-451-5184
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Fax | 708-896-6580
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Provider Business Mailing Address
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Address Line | 1525 E 53RD ST STE 411
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City | CHICAGO
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State | IL
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Zip | 60615-4530
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Country | US
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Telephone | 312-451-5184
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Fax | 708-896-6580
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Authorized Official
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Title or Position | DUI / TREATMENT PROVIDER
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Name | PAUL FITZGERALD JORDAN
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Credential | CADC, MISA I, DUI
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Telephone | 312-451-5184
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 302F00000X
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License Number State | IL
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