Provider Demographics
NPI:1508824244
Name:CENTER ON HALSTED
Entity Type:Organization
Organization Name:CENTER ON HALSTED
Other - Org Name:HORIZONS COMMUNITY SERVICES INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MODESTO
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-472-6469
Mailing Address - Street 1:3656 N HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-4316
Mailing Address - Country:US
Mailing Address - Phone:773-472-6469
Mailing Address - Fax:773-472-6643
Practice Address - Street 1:3656 N HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-4316
Practice Address - Country:US
Practice Address - Phone:773-472-6469
Practice Address - Fax:773-472-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01634461OtherBCBS