Healthcare Provider Details

I. General information

NPI: 1407587124
Provider Name (Legal Business Name): NEW ST PAUL CHURCH OF GOD IN CHRIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2022
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 W MARQUETTE RD
CHICAGO IL
60636-2537
US

IV. Provider business mailing address

2113 W MARQUETTE RD
CHICAGO IL
60636-2537
US

V. Phone/Fax

Practice location:
  • Phone: 773-416-1651
  • Fax:
Mailing address:
  • Phone: 773-416-1651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. RORY HOOD
Title or Position: ADMINISTRATOR
Credential:
Phone: 773-416-1651