1912170457 NPI number — CHRISTIAN COMMUNITY HEALTH CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912170457 NPI number — CHRISTIAN COMMUNITY HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTIAN COMMUNITY HEALTH CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ROSELAND CHRISTIAN HEALTH MINISTRIES
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912170457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 288080
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60628-8080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-233-4100
Provider Business Mailing Address Fax Number:
773-233-4055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 E SIBLEY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH HOLLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60473-1166
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-596-4111
Provider Business Practice Location Address Fax Number:
773-233-4055
Provider Enumeration Date:
04/04/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BURNETT
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
773-233-4100

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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