Healthcare Provider Details

I. General information

NPI: 1154744480
Provider Name (Legal Business Name): PILSEN-LITTLE VILLAGE COMMUNITY MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1518 E 63RD ST
CHICAGO IL
60637-2921
US

IV. Provider business mailing address

2319 S DAMEN AVE
CHICAGO IL
60608-4209
US

V. Phone/Fax

Practice location:
  • Phone: 773-579-0832
  • Fax: 773-579-0762
Mailing address:
  • Phone: 773-579-0832
  • Fax: 773-579-0762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number04113
License Number StateIL

VIII. Authorized Official

Name: DR. FRANCISCO CISNEROS
Title or Position: PRESIDENT/CEO
Credential: PH.D.
Phone: 773-579-0982