Healthcare Provider Details

I. General information

NPI: 1972847820
Provider Name (Legal Business Name): SOUTH-EAST ASIA CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 04/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 N BROADWAY ST
CHICAGO IL
60640-3004
US

IV. Provider business mailing address

1134 W AINSLIE ST
CHICAGO IL
60640-3602
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-6927
  • Fax: 888-831-5471
Mailing address:
  • Phone: 773-989-7433
  • Fax: 888-831-5471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MRS. FANNY WONG
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 773-989-7433