Provider Demographics
NPI:1144528167
Name:BELOVED COMMUNITY FAMILY WELLNESS CENTER
Entity type:Organization
Organization Name:BELOVED COMMUNITY FAMILY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:NEDA
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:773-651-3828
Mailing Address - Street 1:6821 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60621-1833
Mailing Address - Country:US
Mailing Address - Phone:773-651-3629
Mailing Address - Fax:773-322-1955
Practice Address - Street 1:6821 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60621-1833
Practice Address - Country:US
Practice Address - Phone:773-651-3629
Practice Address - Fax:773-651-1599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-01
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036113305261QC1500X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========0001Medicaid
IL141134Medicare PIN