Organization
NICASA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BRUCE JOHNSON (COO)
(847) 546-6450
Entity
Organization
Contact information
Practice address
31979 N FISH LKAE RD, ROUND LAKE, IL 60073
(847) 546-6450
(847) 546-6760
Mailing address
31979 N FISH LKAE RD, ROUND LAKE, IL 60073
(847) 546-6450
(847) 546-6760
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
CA06140005A
IL
261QR0405X
Substance Use Disorder Rehabilitation Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
A06140001A
STATE OF ILLINOIS
IL
01
—
A06140002A
STATE OF ILLINOIS
IL
01
—
A06140003A
STATE OF ILLINOIS
IL
01
—
A06140004A
STATE OF ILLINOIS
IL
01
—
A06140005A
STATE OF ILLINOIS
IL
05
—
CA06140001A
—
IL
05
—
CA06140002A
—
IL
05
—
CA06140005A
—
IL
Enumeration date
05/03/2007
Last updated
04/06/2021
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