Basic Information
| Provider Information | |||||||||
| NPI: | 1982083754 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF DUPAGE DEPARTMENT OF HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DUPAGE COUNTY HEALTH DEPARTMENT - THE COMMUNITY CENTER (TCC) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 N COUNTY FARM RD | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601873977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306827400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 115 N COUNTY FARM RD | ||||||||
| Address2: | |||||||||
| City: | WHEATON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6306827400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2015 | ||||||||
| LastUpdateDate: | 09/11/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AYALA | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6306827400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COUNTY OF DUPAGE DEPARTMENT OF HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 201614 | 01 | IL | MEDICARE | OTHER |