Provider Demographics
NPI:1811767296
Name:ENGLEWOOD COMMUNITY OUTREACH
Entity type:Organization
Organization Name:ENGLEWOOD COMMUNITY OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANTA
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:872-209-1298
Mailing Address - Street 1:9631 S CICERO AVE # 1356
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3137
Mailing Address - Country:US
Mailing Address - Phone:872-203-1298
Mailing Address - Fax:
Practice Address - Street 1:8848 S LANGLEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-6859
Practice Address - Country:US
Practice Address - Phone:872-209-1298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No251S00000XAgenciesCommunity/Behavioral Health
No253Z00000XAgenciesIn Home Supportive Care