Healthcare Provider Details

I. General information

NPI: 1487670097
Provider Name (Legal Business Name): PCC COMMUNITY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5359 E FULLERTON AVE
CHICAGO IL
60639-1450
US

IV. Provider business mailing address

5359 W FULLERTON AVE
CHICAGO IL
60639-1450
US

V. Phone/Fax

Practice location:
  • Phone: 773-836-2785
  • Fax: 773-836-7381
Mailing address:
  • Phone: 773-836-2785
  • Fax: 773-836-7381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number003
License Number StateIL

VIII. Authorized Official

Name: ROBERT J URSO
Title or Position: PRESIDENT & CEO
Credential:
Phone: 708-383-9786