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General NPI Number Information
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NPI Number | 1962880211
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Entity Type | Organization
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Legal Business Name | WAY BACK INN
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Dates
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Enumeration Date | 05/07/2015
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Last Update Date | 06/14/2022
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Provider Practice Location Address
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Address Line | 412 S. WESLEY
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City | OAK PARK
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State | IL
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Zip | 60302
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Country | US
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Telephone | 708-344-3301
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Fax | 708-344-2944
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Provider Business Mailing Address
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Address Line | 104 OAK STREET
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City | MAYWOOD
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State | IL
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Zip | 60153
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Country | US
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Telephone | 708-344-3301
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Fax | 708-344-2944
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | ANITA PINDIUR
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Credential | MS, LCPC, CADC
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Telephone | 708-344-3301
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number | A-0388-0004-A
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License Number State | IL
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