Healthcare Provider Details

I. General information

NPI: 1639653314
Provider Name (Legal Business Name): PRIMO CENTER FOR WOMEN AND CHILDREN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6212 S SANGAMON ST
CHICAGO IL
60621-2006
US

IV. Provider business mailing address

6212 S SANGAMON ST
CHICAGO IL
60621-2006
US

V. Phone/Fax

Practice location:
  • Phone: 773-826-7991
  • Fax: 773-471-6099
Mailing address:
  • Phone: 773-826-7991
  • Fax: 773-471-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANITA CARTER
Title or Position: DIRECTOR OF BILLING/MANAGE CARE STR
Credential:
Phone: 773-826-7991