Healthcare Provider Details

I. General information

NPI: 1841255577
Provider Name (Legal Business Name): SIXTEENTH STREET COMMUNITY HEALTH CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 05/03/2023
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 S CESAR E CHAVEZ DR
MILWAUKEE WI
53204-2203
US

IV. Provider business mailing address

PO BOX 778789
CHICAGO IL
60677-8789
US

V. Phone/Fax

Practice location:
  • Phone: 414-672-1353
  • Fax: 262-408-5094
Mailing address:
  • Phone: 414-672-1353
  • Fax: 262-408-5094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIA CECILIA S TAYLOR
Title or Position: CFO
Credential:
Phone: 414-803-6395