Healthcare Provider Details

I. General information

NPI: 1760272645
Provider Name (Legal Business Name): PCC COMMUNITY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 W LAKE ST
CHICAGO IL
60644
US

IV. Provider business mailing address

14 LAKE ST
OAK PARK IL
60302-2606
US

V. Phone/Fax

Practice location:
  • Phone: 773-378-3347
  • Fax: 773-378-4028
Mailing address:
  • Phone: 708-406-3927
  • Fax: 708-406-3919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: ALYSSA N SIANGHIO
Title or Position: CEO/PRESIDENT
Credential:
Phone: 708-524-7686