Provider Demographics
NPI:1457539223
Name:PLCCA,INC.
Entity Type:Organization
Organization Name:PLCCA,INC.
Other - Org Name:PROVISO LEYDEN COUNCIL FOR COMMUNITY ACTION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PASTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLAUDE
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:BISHOP
Authorized Official - Phone:708-450-3506
Mailing Address - Street 1:411 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-2136
Mailing Address - Country:US
Mailing Address - Phone:708-450-3500
Mailing Address - Fax:708-236-5186
Practice Address - Street 1:411 MADISON ST
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-2136
Practice Address - Country:US
Practice Address - Phone:708-450-3500
Practice Address - Fax:708-236-5186
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PLCCA,INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-04
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0-577-0183-P251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid