Provider Demographics
NPI:1063702330
Name:ICAN COMMUNITY SERVICES INC. NFP
Entity type:Organization
Organization Name:ICAN COMMUNITY SERVICES INC. NFP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:OLUJIMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:708-297-8580
Mailing Address - Street 1:15475 S PARK AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1328
Mailing Address - Country:US
Mailing Address - Phone:708-596-5680
Mailing Address - Fax:
Practice Address - Street 1:15475 S PARK AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1328
Practice Address - Country:US
Practice Address - Phone:708-596-5680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-5212-0001-A261QM2800X, 261QR0405X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL-10,172MOtherFDA NUMBER