Provider Demographics
NPI:1508492745
Name:OAK BROOK CLINIC, LLC
Entity Type:Organization
Organization Name:OAK BROOK CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF QUALITY MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:P
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-339-1436
Mailing Address - Street 1:2605 W 22ND ST STE 29
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-4625
Mailing Address - Country:US
Mailing Address - Phone:630-819-8100
Mailing Address - Fax:630-568-3362
Practice Address - Street 1:2605 W 22ND ST STE 29
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-4625
Practice Address - Country:US
Practice Address - Phone:630-819-8100
Practice Address - Fax:630-568-3362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-19
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA-2158-0000-AOtherSTATE OF ILLINOIS, SUPR