Healthcare Provider Details

I. General information

NPI: 1487193181
Provider Name (Legal Business Name): MILE SQUARE ENGLEWOOD/COOK SATELLITE HEALTH AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 S BISHOP ST
CHICAGO IL
60620-3854
US

IV. Provider business mailing address

8150 S BISHOP ST
CHICAGO IL
60620-3854
US

V. Phone/Fax

Practice location:
  • Phone: 773-783-1370
  • Fax: 773-783-1356
Mailing address:
  • Phone: 773-783-1370
  • Fax: 773-783-1356

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. HENRY TAYLOR
Title or Position: EXCETIVE DIRECTOR
Credential:
Phone: 312-413-1261