Healthcare Provider Details

I. General information

NPI: 1144528167
Provider Name (Legal Business Name): BELOVED COMMUNITY FAMILY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 S HALSTED ST
CHICAGO IL
60621-1833
US

IV. Provider business mailing address

6821 S HALSTED ST
CHICAGO IL
60621-1833
US

V. Phone/Fax

Practice location:
  • Phone: 773-651-3629
  • Fax: 773-651-1599
Mailing address:
  • Phone: 773-651-3629
  • Fax: 773-322-1955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number036113305
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MS. MARGIE NEDA JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MS
Phone: 773-651-3828