=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457539223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLCCA,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2008
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 411 MADISON ST
-----------------------------------------------------
City | MAYWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60153-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-450-3500
-----------------------------------------------------
Fax | 708-236-5186
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 411 MADISON ST
-----------------------------------------------------
City | MAYWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60153-2136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-450-3500
-----------------------------------------------------
Fax | 708-236-5186
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PASTOR
-----------------------------------------------------
Name | MR. CLAUDE PORTER
-----------------------------------------------------
Credential | BISHOP
-----------------------------------------------------
Telephone | 708-450-3506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 0-577-0183-P
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------