Healthcare Provider Details

I. General information

NPI: 1609892223
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: 01/10/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5461 W LAKE ST
CHICAGO IL
60644-2342
US

IV. Provider business mailing address

14 LAKE ST
OAK PARK IL
60302-2606
US

V. Phone/Fax

Practice location:
  • Phone: 773-378-3347
  • Fax: 773-378-4028
Mailing address:
  • Phone: 708-406-3927
  • Fax: 708-406-3919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number002
License Number StateIL

VIII. Authorized Official

Name: ALYSSA SIANGHIO
Title or Position: PRESIDENT CEO
Credential:
Phone: 708-524-7686