Provider Demographics
NPI:1760630750
Name:PCC COMMUNITY WELLNESS CENTER
Entity Type:Organization
Organization Name:PCC COMMUNITY WELLNESS CENTER
Other - Org Name:INTERFAITH HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:URSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-383-9786
Mailing Address - Street 1:3456 W FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-1308
Mailing Address - Country:US
Mailing Address - Phone:773-533-3107
Mailing Address - Fax:
Practice Address - Street 1:3456 W FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-1308
Practice Address - Country:US
Practice Address - Phone:773-533-3107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PCC COMMUNITY WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL006261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========006Medicaid