Healthcare Provider Details

I. General information

NPI: 1124955265
Provider Name (Legal Business Name): SOUTH SIDE HEALTHY COMMUNITY ORGANIZATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7936 S COTTAGE GROVE AVE FL 2
CHICAGO IL
60619-3911
US

IV. Provider business mailing address

7936 S COTTAGE GROVE AVE FL 2
CHICAGO IL
60619-3911
US

V. Phone/Fax

Practice location:
  • Phone: 872-274-4688
  • Fax:
Mailing address:
  • Phone: 872-274-4688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE MICHELLE BARNETT
Title or Position: VP PEOPLE & OPERATIONS
Credential:
Phone: 773-885-5507