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NPI Code Detail

MEDICARE: PCC COMMUNITY WELLNESS CENTER

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
1261QF0400XFederally Qualified Health Center (FQHC)003IL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1141032OTHERMEDICARE PART A PROVIDER NUMBER

General Provider Information

NPI Number : 1487670097
Entity Type Code : Organization
Provider Name (Legal Business Name) : PCC COMMUNITY WELLNESS CENTER
Provider Business Mailing Address
First Line : 5359 W FULLERTON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60639-1450
Country : US
Telephone Number : 773-836-2785
Fax Number : 773-836-7381
Provider Business Practice Location Address
First Line : 5359 E FULLERTON AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60639-1450
Country : US
Telephone Number : 773-836-2785
Fax Number : 773-836-7381
Authorized Official
Title or Position : PRESIDENT & CEO
Name : ROBERT J URSO
Credential :
Telephone Number : 708-383-9786
Provider Enumeration Date : 07/15/2006
Last Update Date : 07/21/2022

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Directions to “PCC COMMUNITY WELLNESS CENTER ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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