Healthcare Provider Details

I. General information

NPI: 1508629478
Provider Name (Legal Business Name): RENEWAL LIFE COMMUNITY DEVELOPMENT CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 W 59TH ST
CHICAGO IL
60621-2823
US

IV. Provider business mailing address

5848 S EMERALD AVE
CHICAGO IL
60621-2814
US

V. Phone/Fax

Practice location:
  • Phone: 773-954-6483
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VCHANEY BROWN
Title or Position: DIRECTOR
Credential: MA,CADC,NCC
Phone: 312-634-6447