Healthcare Provider Details

I. General information

NPI: 1427635358
Provider Name (Legal Business Name): PCC COMMUNITY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 W LAKE ST
CHICAGO IL
60644-2342
US

IV. Provider business mailing address

5425 W LAKE ST
CHICAGO IL
60644-2342
US

V. Phone/Fax

Practice location:
  • Phone: 708-434-4007
  • Fax:
Mailing address:
  • Phone: 708-434-4007
  • Fax:

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: ALYSSA N SIANGHIO
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 708-383-9786