NPIMap

Organization Active NPI

PCC Community Wellness Center

Doing business as Salud Family Health Center

  • Federally Qualified Health Center (FQHC)
  • Chicago, IL
National Provider Identifier
1487670097
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
License
003 Issued in IL
Legal business name
PCC COMMUNITY WELLNESS CENTER
Doing business as
Salud Family Health Center
Practice address
5359 E Fullerton Ave
Chicago, IL 60639-1450
Phone
(773) 836-2785
Fax
(773) 836-7381
NPI assigned
Jul 15, 2006
Last updated
Jul 21, 2022By the provider in NPPES
Organization subpart
Yes
Parent organization
PCC COMMUNITY WELLNESS CENTERAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Robert J Urso
Title
President & Ceo
Phone
(708) 383-9786

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Federally Qualified Health Center (FQHC) 261QF0400X 003 IL Primary

Addresses

Primary practice location

5359 E Fullerton Ave
Chicago, IL 60639-1450

Mailing address

5359 W Fullerton Ave
Chicago, IL 60639-1450
Phone (773) 836-2785

Other identifiers 1

IdentifierTypeStateIssuer
141032OtherMEDICARE PART A PROVIDER NUMBER

Other names 1

  • Salud Family Health Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060811000187 IL Part A Provider - Federally Qualified Health Center (FQHC) 1557270139 Practice locations: Chicago, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1487670097. Details of each certification follow.

Federally qualified health center certification: CCN 141032

Legal name
PCC COMMUNITY WELLNESS CENTER
Doing business as
SALUD FAMILY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Sep 28, 2006
Last certification
Sep 28, 2006
Ownership / control type
For profit – partnership
Organization structure
CorporationNon-profit
Incorporated
Apr 14, 1992 in IL
Enrollment address
5359W Fullerton Ave
Chicago, IL 60639-1450

Other NPIs with the same Medicare PAC ID 16

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 16

National Provider Directory

National Provider Directory
Tax ID family
PCC Community Wellness Ctr21 organizations share this tax ID, including this one
Part of
PCC Community Wellness Ctr

Other organizations with this tax ID 20

Organizations that report the same tax identification number in the National Provider Directory.

View all 20

Locations

5359 W Fullerton Ave
Chicago, IL 60639
Phone (773) 836-2785

Ownership & related parties

All disclosed owners & managing parties 17

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Sonia Taylor Individual Corporate DirectorSenior Director of Finance Jan 28, 2024
W-2 Managing Employee Jan 28, 2024
Alyssa Sianghio Individual Corporate OfficerPresident and Ceo Apr 10, 2024 100%
W-2 Managing Employee Apr 10, 2024 100%
John McDonnell Individual Corporate DirectorBoard Member Jul 26, 2011
Patricia Ford Individual Corporate DirectorBoard Member Aug 25, 2009
Richard Ducatenzeller Individual Corporate DirectorBoard Member Jul 1, 2024
Christopher Barracks Individual Corporate DirectorBoard Member Jan 1, 2024
Ron Austin Individual Corporate DirectorBoard Member Jun 8, 2001
Nilsa Campos Individual Corporate OfficerChief Operations Officer Sep 1, 2021 100%
W-2 Managing Employee Sep 1, 2021 100%
Velda Brunner Individual Corporate DirectorBoard Member Nov 29, 2015
Hiren Patel Individual Corporate OfficerChief Financial Officer Sep 11, 2024 100%
W-2 Managing Employee Sep 11, 2024 100%
Jerrard D Walker Individual Corporate OfficerChief Population Health Officer Dec 1, 2020 100%
W-2 Managing Employee Dec 1, 2020 100%
Janet Y Forbes Individual Corporate DirectorBoard Member Oct 25, 2022
Wrenetha Julion Individual Corporate DirectorBoard Member Jun 23, 2020
Sara Hogue Individual Corporate OfficerChief Quality Improvement Officer Nov 4, 2019 100%
W-2 Managing Employee Nov 4, 2019 100%
Melissa Kirk Individual Corporate DirectorBoard Member Aug 1, 2024
Paul Luning Individual Corporate OfficerChief Medical Officer Sep 17, 2007 100%
W-2 Managing EmployeeChief Medical Officer Sep 17, 2007 100%
Kenneth M Blair Individual Corporate DirectorBoard Treasurer Jul 31, 1992

Owners & managing parties with NPI records 2

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 2

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
PCC Dr Tong Health CenterOak Park, IL, CCN 141034 Federally qualified health center Other (100%) Sep 15, 2004
PCC Walk-in Wellness Center at West Suburban Medical CenterOak Park, IL, CCN 781802 Federally qualified health center Other (100%) Sep 15, 2004

Owned or controlled facilities with NPI records 2

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1152921600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1487670097",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5359 W FULLERTON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606391450",
            "telephone_number": "773-836-2785",
            "fax_number": "773-836-7381"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5359 E FULLERTON AVE",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606391450",
            "telephone_number": "773-836-2785",
            "fax_number": "773-836-7381"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PCC COMMUNITY WELLNESS CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PCC COMMUNITY WELLNESS CENTER",
        "enumeration_date": "2006-07-15",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "URSO",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT & CEO",
        "authorized_official_telephone_number": "708-383-9786"
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "IL",
            "license": "003",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PART A PROVIDER NUMBER",
            "identifier": "141032",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Salud Family Health Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Chicago, IL

Sources for this page

Verify at the official NPI Registry.