Healthcare Provider Details

I. General information

NPI: 1053567966
Provider Name (Legal Business Name): INFANT WELFARE SOCIETY OF CHGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 09/10/2024
Certification Date: 03/25/2022
Deactivation Date: 09/03/2024
Reactivation Date: 09/10/2024

III. Provider practice location address

3600 W FULLERTON AVE
CHICAGO IL
60647-2319
US

IV. Provider business mailing address

3600 W FULLERTON AVE
CHICAGO IL
60647-2319
US

V. Phone/Fax

Practice location:
  • Phone: 773-782-2800
  • Fax: 773-782-5042
Mailing address:
  • Phone: 773-782-2800
  • Fax: 773-782-5056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number002
License Number StateIL

VIII. Authorized Official

Name: JOSE GALARZA
Title or Position: CHIEF HEALTHCARE ANALYTICS OFFICER
Credential:
Phone: 773-782-5035