Healthcare Provider Details

I. General information

NPI: 1578787644
Provider Name (Legal Business Name): PILSEN-LITTLE VILLAGE COMMUNITY MENTAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 W CERMAK RD
CHICAGO IL
60623-3449
US

IV. Provider business mailing address

2319 S DAMEN AVE
CHICAGO IL
60608-4209
US

V. Phone/Fax

Practice location:
  • Phone: 773-277-3413
  • Fax: 773-277-3517
Mailing address:
  • Phone: 773-579-0832
  • Fax: 773-579-0762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. FRANCISCO CISNEROS
Title or Position: EXECUTIVE DIRECTOR
Credential: MA
Phone: 773-579-0832