Healthcare Provider Details

I. General information

NPI: 1962218834
Provider Name (Legal Business Name): FEDERACION DE CLUBES MICHOACANOS EN ILLINOIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2024
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 S BLUE ISLAND AVE
CHICAGO IL
60608-2134
US

IV. Provider business mailing address

1638 S BLUE ISLAND AVE
CHICAGO IL
60608-2134
US

V. Phone/Fax

Practice location:
  • Phone: 312-491-9317
  • Fax:
Mailing address:
  • Phone: 312-491-9317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ARIANA GARFIAS
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 312-491-9317