Healthcare Provider Details

I. General information

NPI: 1346230299
Provider Name (Legal Business Name): CHILD & ADOLESCENT HEALTH ASSOC LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 11/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 N CLARK ST SUITE 400
CHICAGO IL
60610-5467
US

IV. Provider business mailing address

PO BOX 189
MATTESON IL
60443-0189
US

V. Phone/Fax

Practice location:
  • Phone: 312-943-6964
  • Fax: 312-943-6924
Mailing address:
  • Phone: 708-747-5850
  • Fax: 708-747-9991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ALETA CLARK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-943-6964