Healthcare Provider Details

I. General information

NPI: 1720104573
Provider Name (Legal Business Name): PCC COMMUNITY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SUPERIOR ST SUITE 207
MELROSE PARK IL
60160-4138
US

IV. Provider business mailing address

1111 SUPERIOR ST SUITE 207
MELROSE PARK IL
60160-4138
US

V. Phone/Fax

Practice location:
  • Phone: 708-406-3040
  • Fax: 708-406-3059
Mailing address:
  • Phone: 708-406-3040
  • Fax: 708-406-3059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number011
License Number StateIL

VIII. Authorized Official

Name: ROBERT J URSO
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 708-383-9786