Healthcare Provider Details

I. General information

NPI: 1720467798
Provider Name (Legal Business Name): SACRED CIRCLES HEALTH INITIATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2015
Last Update Date: 05/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W HARRISON ST
CHICAGO IL
60612-3741
US

IV. Provider business mailing address

PO BOX 12002
CHICAGO IL
60612-0002
US

V. Phone/Fax

Practice location:
  • Phone: 312-572-4539
  • Fax:
Mailing address:
  • Phone: 773-717-6759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. GLENN HARRISON
Title or Position: OWNER
Credential: M.D.
Phone: 773-717-6759