MEDICARE: PCC COMMUNITY WELLNESS CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1255701942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PCC COMMUNITY WELLNESS CENTER

Provider Business Mailing Address
First Line	:	14 LAKE ST
Second Line	:
City	:	OAK PARK
State	:	IL
Zip	:	60302-2606
Country	:	US
Telephone Number	:	708-383-0113
Fax Number	:	708-383-1378

Provider Business Practice Location Address
First Line	:	3030 N MOBILE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60634-4041
Country	:	US
Telephone Number	:	708-406-3041
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	ALYSSA N SIANGHIO
Credential	:
Telephone Number	:	708-383-9786

Provider Enumeration Date	:	10/07/2015
Last Update Date	:	01/09/2026

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