MEDICARE: UCAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124476726
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UCAN

Provider Business Mailing Address
First Line	:	3605 W FILLMORE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-4310
Country	:	US
Telephone Number	:	773-588-0180
Fax Number	:

Provider Business Practice Location Address
First Line	:	3640 W FILLMORE ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60624-4309
Country	:	US
Telephone Number	:	773-588-0180
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE ASSISTANT
Name	:	JONATHAN STACY
Credential	:
Telephone Number	:	773-588-0180

Provider Enumeration Date	:	05/25/2016
Last Update Date	:	12/22/2016

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Directions to “UCAN ” Practice Location

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