Provider Demographics
NPI:1386981264
Name:CENTRO DE SALUD Y ESPERANZA
Entity type:Organization
Organization Name:CENTRO DE SALUD Y ESPERANZA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FULWILER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-584-6130
Mailing Address - Street 1:3059 W 26TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-4131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 S CALIFORNIA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-2486
Practice Address - Country:US
Practice Address - Phone:773-584-6133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRO DE SALUD Y ESPERANZA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-11
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)