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12139 S. Western Ave Blue Island IL 60406 | |
| (877) 692-8686 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 12139 S. Western Ave, Blue Island, Illinois |
| Authorized Official Name and Position | Audrey Pennington (EXECUTIVE VP OF HEALTH) |
| Authorized Official Contact | 7738027645 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
19900 Governors Dr Olympia Fields IL 60461-1057 Ph: () - | 12139 S. Western Ave Blue Island IL 60406 Ph: (877) 692-8686 |
| NPI Number | 1174070676 |
|---|---|
| Provider Enumeration Date | 09/01/2016 |
| Last Update Date | 01/13/2017 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1174070676 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
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