Healthcare Provider Details

I. General information

NPI: 1831590421
Provider Name (Legal Business Name): LAWNDALE CHRISTIAN HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2014
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 W CARROLL AVE
CHICAGO IL
60624-2031
US

IV. Provider business mailing address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

V. Phone/Fax

Practice location:
  • Phone: 872-588-3000
  • Fax:
Mailing address:
  • Phone: 872-588-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: KAREN RENEE JOHNSON
Title or Position: ASST DIR OF PATIENT ACCOUNTING
Credential:
Phone: 872-588-3000