Provider Demographics
NPI:1346707254
Name:THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Entity Type:Organization
Organization Name:THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Other - Org Name:MILE SQUARE DR. CYNTHIA BARNES-BOYD/DRAKE HEALTH AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LEVITSKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-996-0566
Mailing Address - Street 1:818 S WOLCOTT AVE STE 811
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3702
Mailing Address - Country:US
Mailing Address - Phone:312-996-9787
Mailing Address - Fax:312-996-3848
Practice Address - Street 1:2710 S DEARBORN ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2684
Practice Address - Country:US
Practice Address - Phone:312-355-5746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-27
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)