MEDICARE: FRIEND FAMILY HEALTH CENTER, INC

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1457330870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRIEND FAMILY HEALTH CENTER, INC

Provider Business Mailing Address
First Line	:	5843 S. WESTERN AVENUE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60636
Country	:	US
Telephone Number	:	773-702-2193
Fax Number	:	773-702-4356

Provider Business Practice Location Address
First Line	:	5843 S. WESTERN AVENUE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60636
Country	:	US
Telephone Number	:	773-702-2193
Fax Number	:	773-702-4356

Authorized Official
Title or Position	:	CFO
Name	:	SABRINA MODRE
Credential	:
Telephone Number	:	773-702-2193

Provider Enumeration Date	:	01/13/2006
Last Update Date	:	10/01/2009

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