Provider Demographics
NPI:1760408439
Name:BELOVED COMMUNITY FAMILY WELLNESS CENTER
Entity Type:Organization
Organization Name:BELOVED COMMUNITY FAMILY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-651-3828
Mailing Address - Street 1:326 W 64TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-3114
Mailing Address - Country:US
Mailing Address - Phone:773-651-3828
Mailing Address - Fax:773-651-3648
Practice Address - Street 1:6821 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-1833
Practice Address - Country:US
Practice Address - Phone:773-765-1382
Practice Address - Fax:773-651-3648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2300X261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========0001Medicaid
IL=========OtherORGANIZATION
IL=========0001Medicaid