MEDICARE: LAWNDALE CHRISTIAN HEALTH CENTER

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	261QP2300X	Primary Care Clinic/Center	209010903	IL

General Provider Information

NPI Number	:	1366872061
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAWNDALE CHRISTIAN HEALTH CENTER

Provider Business Mailing Address
First Line	:	3860 W OGDEN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60623-2460
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5122 S ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-4508
Country	:	US
Telephone Number	:	872-522-3560
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	KIWANI COOPER
Credential	:
Telephone Number	:	872-588-3027

Provider Enumeration Date	:	11/15/2013
Last Update Date	:	11/15/2013

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Directions to “LAWNDALE CHRISTIAN HEALTH CENTER ” Practice Location

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