1770785644 NPI number — CHICAGO FAMILY HEALTH CENTER, INC.

Table of content: (NPI 1770785644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770785644 NPI number — CHICAGO FAMILY HEALTH CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHICAGO FAMILY HEALTH CENTER, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1770785644
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9119 S EXCHANGE AVE
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:
60617-4225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-768-5000
Provider Business Mailing Address Fax Number:
773-768-6153

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 W. 111TH ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-768-5000
Provider Business Practice Location Address Fax Number:
773-374-1621
Provider Enumeration Date:
06/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BOKLAGE
Authorized Official First Name:
JOSEPH
Authorized Official Middle Name:
ERIC
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
773-768-5000

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14D1053833 . This is a "CLIA LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 1697382 . This is a "CITY LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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