Provider Demographics
NPI:1649559642
Name:SIXTEENTH STREET COMMUNITY HEALTH CENTERS, INC.
Entity Type:Organization
Organization Name:SIXTEENTH STREET COMMUNITY HEALTH CENTERS, INC.
Other - Org Name:UNITED COMMUNITY CENTER GERIATRIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARIA CECILIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-803-6395
Mailing Address - Street 1:PO BOX 778789
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-8789
Mailing Address - Country:US
Mailing Address - Phone:414-672-1353
Mailing Address - Fax:262-408-5094
Practice Address - Street 1:730 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-2310
Practice Address - Country:US
Practice Address - Phone:414-672-1353
Practice Address - Fax:262-408-5094
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIXTEENTH STREET COMMUNITY HEALTH CENTERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-08
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1507-800261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1649559642Medicaid
WI000001545Medicare PIN