Healthcare Provider Details

I. General information

NPI: 1619612835
Provider Name (Legal Business Name): SIXTEENTH STREET COMMUNITY HEALTH CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 05/02/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 S 9TH ST
MILWAUKEE WI
53204-1361
US

IV. Provider business mailing address

PO BOX 778789
CHICAGO IL
60677-0001
US

V. Phone/Fax

Practice location:
  • Phone: 414-672-1353
  • Fax:
Mailing address:
  • Phone: 414-672-1353
  • Fax: 414-672-0191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARIA CECILIA S TAYLOR
Title or Position: CFO
Credential:
Phone: 414-897-5407