Provider Demographics
NPI:1487193181
Name:MILE SQUARE ENGLEWOOD/COOK SATELLITE HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:MILE SQUARE ENGLEWOOD/COOK SATELLITE HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXCETIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-413-1261
Mailing Address - Street 1:8150 S BISHOP ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-3854
Mailing Address - Country:US
Mailing Address - Phone:773-783-1370
Mailing Address - Fax:773-783-1356
Practice Address - Street 1:8150 S BISHOP ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-3854
Practice Address - Country:US
Practice Address - Phone:773-783-1370
Practice Address - Fax:773-783-1356
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-15
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)