NPIMap

Organization Active NPI

Christian Community Health Center

  • Federally Qualified Health Center (FQHC)
  • South Holland, IL
National Provider Identifier
1912170457
Registry record updated Sep 19, 2023
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
901 E Sibley Blvd
South Holland, IL 60473-1166
Phone
(708) 596-4111
Fax
(773) 233-4055
NPI assigned
Apr 4, 2008
Last updated
Sep 19, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 19, 2023

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 2

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

Addresses

Primary practice location

901 E Sibley Blvd
South Holland, IL 60473-1166

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 IL2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20040108000515 IL Part B Supplier - Clinic/Group Practice 4284533183 Receives reassigned benefits from 27 practitioners
3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Calumet City, IL; Chicago, IL; Lansing, IL; South Holland, IL
O20070614000454 IL Part A Provider - Federally Qualified Health Center (FQHC) 4284533183 1 other NPI on this enrollment
Practice locations: South Holland, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1912170457. Details of each certification follow.

Federally qualified health center certification: CCN 141041

Legal name
CHRISTIAN COMMUNITY HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jun 15, 2007
Last certification
Jun 15, 2007
Ownership / control type
For profit – individual
Organization structure
CorporationNon-profit
Incorporated
Dec 18, 1991 in IL
Enrollment address
901 E Sibley Blvd
South Holland, IL 60473-1166

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 3

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
14D1077135Christian Community Health Center901 E Sibley Blvd, South Holland, IL 60473Provider-performed microscopyFeb 17, 2028

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.

Locations

901 E Sibley Blvd
South Holland, IL 60473
Phone (708) 333-8020

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 Jan 1, 2015
Lester Barclay Individual Corporate OfficerBoard Member Jan 1, 2015
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

Practitioners & affiliated clinicians

Practitioners 10

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

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": "1695081600000",
    "number": "1912170457",
    "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": "901 E SIBLEY BLVD",
            "city": "SOUTH HOLLAND",
            "state": "IL",
            "postal_code": "604731166",
            "telephone_number": "708-596-4111",
            "fax_number": "773-233-4055"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CHRISTIAN COMMUNITY HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-04-04",
        "last_updated": "2023-09-19",
        "certification_date": "2023-09-19",
        "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": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ROSELAND CHRISTIAN HEALTH MINISTRIES",
            "code": "4",
            "type": "Former Legal Business Name"
        },
        {
            "organization_name": "ROSELAND CHRISTIAN HEALTH MINISTRIES",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in South Holland, IL

Sources for this page

Verify at the official NPI Registry.