Provider Demographics
NPI:1497293344
Name:MILE SQUARE DAVIS/BRIGHTON PARK SATELLITE HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:MILE SQUARE DAVIS/BRIGHTON PARK SATELLITE HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE 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:312-412-1261
Mailing Address - Street 1:3825 S WASHTENAW AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-1633
Mailing Address - Country:US
Mailing Address - Phone:773-376-5293
Mailing Address - Fax:
Practice Address - Street 1:3825 S WASHTENAW AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-1633
Practice Address - Country:US
Practice Address - Phone:773-376-5293
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE BOARD OF TRUSTEES OF THE UNIVERSITY OF ILLINOIS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-10
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)