Provider Demographics
NPI:1750621769
Name:PCC COMMUNITY WELLNESS CENTER
Entity type:Organization
Organization Name:PCC COMMUNITY WELLNESS CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:3 ERIE CT
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2519
Mailing Address - Country:US
Mailing Address - Phone:708-383-9786
Mailing Address - Fax:
Practice Address - Street 1:3 ERIE CT
Practice Address - Street 2:SUITE 1300
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2519
Practice Address - Country:US
Practice Address - Phone:708-383-9786
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PCC COMMUNITY WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)