Provider Demographics
NPI:1457330870
Name:FRIEND FAMILY HEALTH CENTER, INC
Entity Type:Organization
Organization Name:FRIEND FAMILY HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:SABRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MODRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-702-2193
Mailing Address - Street 1:5843 S. WESTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60636
Mailing Address - Country:US
Mailing Address - Phone:773-702-2193
Mailing Address - Fax:773-702-4356
Practice Address - Street 1:5843 S. WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60636
Practice Address - Country:US
Practice Address - Phone:773-702-2193
Practice Address - Fax:773-702-4356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2009-10-01
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=========002Medicaid
IL141984Medicare ID - Type UnspecifiedFQHC