- Enrollment id
- O20201214000484
- Enrollment state
- IN
- Provider type code
- 00-04
- Provider type text
- PART A PROVIDER - FEDERALLY QUALIFIED HEALTH CENTER (FQHC)
- Npi
- 1003410085
- Multiple npi flag
- N
- Ccn
- 151088
- Associate id
- 0547521452
- Organization name
- 219 HEALTH NETWORK INC
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- N
- Address line 1
- 4320 FIR ST
- Address line 2
- UNIT 216
- City
- EAST CHICAGO
- State
- IN
- Zip code
- 463123076
- Telephone number
- 2197039251