NPIMap

Organization Active NPI

Christian Community Health Center

  • Federally Qualified Health Center (FQHC)
  • Calumet City, IL
National Provider Identifier
1780857219
Registry record updated Feb 9, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
CHRISTIAN COMMUNITY HEALTH CENTER
Practice address
364 Torrence Ave
Calumet City, IL 60409-1902
Phone
(708) 868-9457
NPI assigned
Apr 4, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 9, 2022

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

Authorized official

Name
Mr. Kenneth A. Burnett, M.S.
Title
Chief Executive Officer
Phone
(773) 233-4100

Specialties & licenses 1

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

Addresses

Primary practice location

364 Torrence Ave
Calumet City, IL 60409-1902

Mailing address

PO Box 288080
Chicago, IL 60628-8080
Phone (773) 233-4100

Other names 1

  • ROSELAND CHRISTIAN HEALTH MINISTRIES Former legal business name

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050121000152 IL Part A Provider - Federally Qualified Health Center (FQHC) 4284533183 1 other NPI on this enrollment
Practice locations: Calumet City, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1780857219. Details of each certification follow.

Federally qualified health center certification: CCN 141003

Legal name
CHRISTIAN COMMUNITY HEALTH CENTER
Doing business as
ROSELAND CHRISTIAN HEALTH MINISTRIES
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Mar 17, 2005
Last certification
Mar 17, 2005
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 18, 1991 in IL
Enrollment address
364 Torrence Ave
Calumet City, IL 60409-1902
Related CCNs
141878

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 3

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

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Christian Community Health Center7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

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

Ownership & related parties

All disclosed owners & managing parties 10

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

NameRoleSinceShare
Latoya Dixon Individual Corporate OfficerSecretary Jan 1, 2015
Shawn Spearman Individual Corporate OfficerBoard Member Jan 1, 2015
Dana Garner Individual Corporate OfficerTreasurer Jun 1, 2016
Lester Barclay Individual Corporate OfficerBoard Member Jun 1, 2006
Sanara Leake Individual W-2 Managing EmployeeRevenue Cycle Manager Aug 3, 2021
Jetuan Grayson Individual Corporate OfficerBoard Member Jan 1, 2015
Kenneth Burnett Individual Corporate DirectorChief Executive Officer Jan 1, 2015
Warren Broome Individual Corporate OfficerBoard Member Jan 1, 2015
Will Cobbs Individual Corporate OfficerChairman of the Board Jan 1, 2015
Alfred Smtih Individual Corporate OfficerBoard President Jun 1, 2006

NPI Registry JSON

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

{
    "created_epoch": "1207267200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1644364800000",
    "number": "1780857219",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 288080",
            "city": "CHICAGO",
            "state": "IL",
            "postal_code": "606288080",
            "telephone_number": "773-233-4100",
            "fax_number": "773-233-4055"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "364 TORRENCE AVE",
            "city": "CALUMET CITY",
            "state": "IL",
            "postal_code": "604091902",
            "telephone_number": "708-868-9457"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHRISTIAN COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-04",
        "last_updated": "2022-02-09",
        "certification_date": "2022-02-09",
        "status": "A",
        "authorized_official_last_name": "BURNETT",
        "authorized_official_first_name": "KENNETH",
        "authorized_official_middle_name": "A.",
        "authorized_official_title_or_position": "CHIEF EXECUTIVE OFFICER",
        "authorized_official_telephone_number": "773-233-4100",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "M.S."
    },
    "taxonomies": [
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": "IL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ROSELAND CHRISTIAN HEALTH MINISTRIES",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Calumet City, IL

Sources for this page

Verify at the official NPI Registry.