Provider Demographics
NPI:1467839803
Name:WAY BACK INN
Entity Type:Organization
Organization Name:WAY BACK INN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PINDIUR
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LCPC, CADC
Authorized Official - Phone:708-344-3301
Mailing Address - Street 1:104 OAK ST
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-1676
Mailing Address - Country:US
Mailing Address - Phone:708-344-3301
Mailing Address - Fax:708-344-2944
Practice Address - Street 1:104 OAK ST
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-1676
Practice Address - Country:US
Practice Address - Phone:708-344-3301
Practice Address - Fax:708-344-2944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0388-0002-A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility