Healthcare Provider Details

I. General information

NPI: 1376127225
Provider Name (Legal Business Name): SALAAM COMMUNITY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 E 67TH ST
CHICAGO IL
60637-4122
US

IV. Provider business mailing address

18613 JANA PATRICE DR
PFLUGERVILLE TX
78660-7584
US

V. Phone/Fax

Practice location:
  • Phone: 773-207-3540
  • Fax:
Mailing address:
  • Phone: 773-330-4115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. CONSTANCE DIANE SHABAZZ
Title or Position: CEO
Credential: MD
Phone: 773-330-4115