MEDICARE: AUNT MARTHA'S HEALTH AND WELLNESS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1700539517
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUNT MARTHA'S HEALTH AND WELLNESS, INC.

Provider Business Mailing Address
First Line	:	19990 GOVERNORS HWY
Second Line	:
City	:	OLYMPIA FIELDS
State	:	IL
Zip	:	60461-1021
Country	:	US
Telephone Number	:	877-692-8686
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 NE GLEN OAK AVE FL 1
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61603-3106
Country	:	US
Telephone Number	:	877-692-8686
Fax Number	:	708-747-8024

Authorized Official
Title or Position	:	COO
Name	:	MRS. AUDREY PENNINGTON
Credential	:
Telephone Number	:	773-802-7645

Provider Enumeration Date	:	02/01/2022
Last Update Date	:	02/01/2022

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