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General NPI Number Information
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NPI Number | 1649718594
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Entity Type | Organization
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Legal Business Name | MILE SQUARE DRAKE HEALTH AND WELLNESS CENTER
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Dates
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Enumeration Date | 02/10/2017
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Last Update Date | 02/10/2017
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Provider Practice Location Address
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Address Line | 2710 S DEARBORN ST
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City | CHICAGO
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State | IL
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Zip | 60616-2684
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Country | US
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Telephone | 312-949-0379
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Fax | 312-949-1473
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Provider Business Mailing Address
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Address Line | 2710 S DEARBORN ST
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City | CHICAGO
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State | IL
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Zip | 60616-2684
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Country | US
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Telephone | 312-949-0379
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Fax | 312-949-1473
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. HENRY TAYLOR
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Credential |
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Telephone | 312-412-1261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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