Healthcare Provider Details

I. General information

NPI: 1760408439
Provider Name (Legal Business Name): BELOVED COMMUNITY FAMILY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 10/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 S HALSTED ST
CHICAGO IL
60621-1833
US

IV. Provider business mailing address

326 W 64TH ST
CHICAGO IL
60621-3114
US

V. Phone/Fax

Practice location:
  • Phone: 773-765-1382
  • Fax: 773-651-3648
Mailing address:
  • Phone: 773-651-3828
  • Fax: 773-651-3648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number261QP2300X
License Number StateIL

VIII. Authorized Official

Name: MS. MARGIE JOHNSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 773-651-3828