MEDICARE: ENGLEWOOD COMMUNITY CONNECTION OUTREACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1366817017
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENGLEWOOD COMMUNITY CONNECTION OUTREACH

Provider Business Mailing Address
First Line	:	46 E 26TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2304
Country	:	US
Telephone Number	:	773-885-2974
Fax Number	:

Provider Business Practice Location Address
First Line	:	7326 S EXCHANGE AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60649-3408
Country	:	US
Telephone Number	:	773-885-2974
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DELORES TAYLOR
Credential	:	FOUNDER
Telephone Number	:	773-885-2974

Provider Enumeration Date	:	12/07/2015
Last Update Date	:	12/07/2015

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