- Enrollment id
- O20210723001938
- Enrollment state
- IN
- Provider type code
- 00-04
- Provider type text
- PART A PROVIDER - FEDERALLY QUALIFIED HEALTH CENTER (FQHC)
- Npi
- 1811562374
- Multiple npi flag
- N
- Ccn
- 151111
- Associate id
- 0547521452
- Organization name
- 219 HEALTH NETWORK INC
- 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 408
- City
- EAST CHICAGO
- State
- IN
- Zip code
- 463123078
- Telephone number
- 2195544081