Provider Demographics
NPI:1205666096
Name:ENGLEWOOD COMMUNITY OUTREACH
Entity type:Organization
Organization Name:ENGLEWOOD COMMUNITY OUTREACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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 STE 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:872-209-1298
Mailing Address - Fax:
Practice Address - Street 1:9531 S UTICA AVENUE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805
Practice Address - Country:US
Practice Address - Phone:872-209-1298
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-06
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty