Provider Demographics
NPI:1851353361
Name:CRYSTAL LAKE FAMILY TREATMENT CENTER LTD
Entity Type:Organization
Organization Name:CRYSTAL LAKE FAMILY TREATMENT CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BALOCKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-455-0310
Mailing Address - Street 1:185 HERITAGE DRIVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-455-0310
Mailing Address - Fax:815-455-1210
Practice Address - Street 1:185 HERITAGE DRIVE
Practice Address - Street 2:SUITE 3
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014
Practice Address - Country:US
Practice Address - Phone:815-455-0310
Practice Address - Fax:815-455-1210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036073896207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036073896Medicaid
E19063Medicare UPIN
907940Medicare ID - Type Unspecified