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Organization
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Organization
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Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JESSECA WATSON (CREDENTIALING MANAGER)
(331) 442-1127
Entity
Organization
Contact information
Practice address
11440 S INDIANA AVE, CHICAGO, IL 60628-4954
(773) 632-9711
Mailing address
11440 S INDIANA AVE, CHICAGO, IL 60628-4954
(773) 632-9711
Taxonomy
Speciality
Code
Description
License number
State
261QR0800X
Recovery Care Clinic/Center
Primary
—
NULL
Other
Enumeration date
05/23/2021
Last updated
05/23/2021
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