Provider Demographics
NPI:1780857219
Name:CHRISTIAN COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:CHRISTIAN COMMUNITY HEALTH CENTER
Other - Org Name:ROSELAND CHRISTIAN HEALTH MINISTRIES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:773-233-4100
Mailing Address - Street 1:PO BOX 288080
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-8080
Mailing Address - Country:US
Mailing Address - Phone:773-233-4100
Mailing Address - Fax:773-233-4055
Practice Address - Street 1:364 TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-1902
Practice Address - Country:US
Practice Address - Phone:708-868-9457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL141003Medicare Oscar/Certification
IL209742Medicare PIN
IL141003Medicare Oscar/Certification