Organization
PUERTO RICAN CULTURAL CENTER
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JORGE CESTOU MBA (DIRECTOR, PROGRAMS AND SERVICES VS)
(773) 278-6737
Entity
Organization
Contact information
Practice address
2640 W DIVISION ST, CHICAGO, IL 60622-2850
(773) 278-6737
(773) 278-6753
Mailing address
2640 W DIVISION ST, CHICAGO, IL 60622-2850
(773) 278-6737
(773) 278-6753
Taxonomy
Speciality
Code
Description
License number
State
172V00000X
Community Health Worker
Primary
2015
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
14D1023971
CLIA WAIVER
IL
Enumeration date
05/14/2015
Last updated
05/14/2015
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