Healthcare Provider Details

I. General information

NPI: 1497872543
Provider Name (Legal Business Name): INFANT WELFARE SOCIETY OF CHICAGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 W FULLERTON AVE
CHICAGO IL
60647
US

IV. Provider business mailing address

3600 W FULLERTON AVE
CHICAGO IL
60647
US

V. Phone/Fax

Practice location:
  • Phone: 773-782-2800
  • Fax: 773-782-5042
Mailing address:
  • Phone: 773-782-2800
  • Fax: 773-782-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CINDY HERRERA
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 773-782-5024