- Enrollment id
- O20190416000191
- Enrollment state
- IN
- Provider type code
- 00-04
- Provider type text
- PART A PROVIDER - FEDERALLY QUALIFIED HEALTH CENTER (FQHC)
- Npi
- 1578025896
- Multiple npi flag
- N
- Ccn
- 151048
- Associate id
- 0547521452
- Organization name
- 219 HEALTH NETWORK INC
- Doing business as name
- 219 HEALTH NETWORK
- Incorporation date
- 2017-07-27
- Incorporation state
- IN
- Organization type structure
- CORPORATION
- Proprietary nonprofit
- N
- Address line 1
- 4320 FIR ST
- Address line 2
- UNIT 211
- City
- EAST CHICAGO
- State
- IN
- Zip code
- 463123076
- Telephone number
- 2197032577