Provider Demographics
NPI:1164628012
Name:PCC COMMUNITY WELLNESS CENTER
Entity Type:Organization
Organization Name:PCC COMMUNITY WELLNESS CENTER
Other - Org Name:PCC WEST TOWN FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT - CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:URSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-383-9786
Mailing Address - Street 1:2434 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-2942
Mailing Address - Country:US
Mailing Address - Phone:773-292-8300
Mailing Address - Fax:708-292-2601
Practice Address - Street 1:2434 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2942
Practice Address - Country:US
Practice Address - Phone:773-292-8300
Practice Address - Fax:708-292-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========008Medicaid