Provider Demographics
NPI:1124476726
Name:UCAN
Entity type:Organization
Organization Name:UCAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:STACY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-588-0180
Mailing Address - Street 1:3605 W FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-4310
Mailing Address - Country:US
Mailing Address - Phone:773-588-0180
Mailing Address - Fax:
Practice Address - Street 1:3640 W FILLMORE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-4309
Practice Address - Country:US
Practice Address - Phone:773-588-0180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2B05CHR011Medicaid