MEDICARE: PILSEN-LITTLE VILLAGE COMMUNITY MENTAL 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1568839090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PILSEN-LITTLE VILLAGE COMMUNITY MENTAL HEALTH CENTER, INC.

Provider Business Mailing Address
First Line	:	2319 S DAMEN AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-4209
Country	:	US
Telephone Number	:	773-579-0832
Fax Number	:	773-579-0762

Provider Business Practice Location Address
First Line	:	3232 W 55TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60632-2638
Country	:	US
Telephone Number	:	773-424-3060
Fax Number	:	773-424-3368

Authorized Official
Title or Position	:	PRESICENT/CEO
Name	:	DR. FRANCISCO CISNEROS
Credential	:
Telephone Number	:	773-579-0832

Provider Enumeration Date	:	09/01/2015
Last Update Date	:	06/07/2019

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