Healthcare Provider Details

I. General information

NPI: 1063614923
Provider Name (Legal Business Name): CHICAGO FAMILY HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 E 115TH ST
CHICAGO IL
60628-5740
US

IV. Provider business mailing address

9119 S EXCHANGE AVE
CHICAGO IL
60617-4225
US

V. Phone/Fax

Practice location:
  • Phone: 773-768-5000
  • Fax: 773-840-3409
Mailing address:
  • Phone: 773-768-5000
  • Fax: 773-768-6153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH ERIC BOKLAGE
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 773-768-5000