Healthcare Provider Details

I. General information

NPI: 1629456363
Provider Name (Legal Business Name): PUERTO RICAN CULTURAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2015
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 W DIVISION ST
CHICAGO IL
60622-2850
US

IV. Provider business mailing address

2640 W DIVISION ST
CHICAGO IL
60622-2850
US

V. Phone/Fax

Practice location:
  • Phone: 773-278-6737
  • Fax: 773-278-6753
Mailing address:
  • Phone: 773-278-6737
  • Fax: 773-278-6753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number2015
License Number StateIL

VIII. Authorized Official

Name: MR. JORGE CESTOU
Title or Position: DIRECTOR, PROGRAMS AND SERVICES VS
Credential: MBA
Phone: 773-278-6737