Provider Demographics
NPI:1396194692
Name:AMERICAN INDIAN HEALTH SERVICE OF CHICAGO INC
Entity Type:Organization
Organization Name:AMERICAN INDIAN HEALTH SERVICE OF CHICAGO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAVALLIE-UNABIA
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:773-883-9100
Mailing Address - Street 1:4326 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2016
Mailing Address - Country:US
Mailing Address - Phone:773-883-9100
Mailing Address - Fax:773-883-0005
Practice Address - Street 1:4326 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2016
Practice Address - Country:US
Practice Address - Phone:773-883-9100
Practice Address - Fax:773-883-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150014334261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)