Provider Demographics
NPI:1881139418
Name:GREAT HEIGHTS OTP
Entity type:Organization
Organization Name:GREAT HEIGHTS OTP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ADEYEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:FATOKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-952-9378
Mailing Address - Street 1:315 E MCKINLEY RD
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-4805
Mailing Address - Country:US
Mailing Address - Phone:815-434-0228
Mailing Address - Fax:
Practice Address - Street 1:315 E MCKINLEY RD
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-4805
Practice Address - Country:US
Practice Address - Phone:815-434-0228
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREAT HEIGHTS OTP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-06
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA-6548-0002-AOtherSUPR