Provider Demographics
NPI:1316296007
Name:SUNDANCE METHADONE TREATMENT CENTER,LLC
Entity type:Organization
Organization Name:SUNDANCE METHADONE TREATMENT CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:P
Authorized Official - Last Name:WOODARD
Authorized Official - Suffix:
Authorized Official - Credentials:MA/CADC
Authorized Official - Phone:773-769-4545
Mailing Address - Street 1:4545 N BROADWAY ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5975
Mailing Address - Country:US
Mailing Address - Phone:773-784-1111
Mailing Address - Fax:773-784-4910
Practice Address - Street 1:4545 N BROADWAY ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5975
Practice Address - Country:US
Practice Address - Phone:773-784-1111
Practice Address - Fax:773-784-4910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2800X
ILA31350001261QR0400X, 261QR0405X, 276400000X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility