Provider Demographics
NPI:1023442753
Name:PLCCA
Entity type:Organization
Organization Name:PLCCA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DATA/BILLING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:M
Authorized Official - Last Name:YATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-450-3500
Mailing Address - Street 1:411 MADISON W ST
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-2136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 MADISON W ST
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-2136
Practice Address - Country:US
Practice Address - Phone:708-450-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-29
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1215987003Medicaid