MEDICARE: WESTCARE ILLINOIS, INC

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	A-4241-0007-A	IL

General Provider Information

NPI Number	:	1821535618
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTCARE ILLINOIS, INC

Provider Business Mailing Address
First Line	:	1100 W CERMAK RD
Second Line	:	SUITE B414
City	:	CHICAGO
State	:	IL
Zip	:	60608-4500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 W CERMAK RD
Second Line	:	SUITE B414
City	:	CHICAGO
State	:	IL
Zip	:	60608-4500
Country	:	US
Telephone Number	:	312-568-7051
Fax Number	:

Authorized Official
Title or Position	:	REGIONAL VICE PRESEDIENT
Name	:	STAVY MUNROE
Credential	:
Telephone Number	:	312-568-7051

Provider Enumeration Date	:	01/31/2017
Last Update Date	:	01/31/2017

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