Healthcare Provider Details

I. General information

NPI: 1447610381
Provider Name (Legal Business Name): MATHERS CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2016
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 S VIRGINIA ST
CRYSTAL LAKE IL
60014-7226
US

IV. Provider business mailing address

145 S VIRGINIA ST
CRYSTAL LAKE IL
60014-7226
US

V. Phone/Fax

Practice location:
  • Phone: 815-444-9999
  • Fax: 815-986-1363
Mailing address:
  • Phone: 815-444-9999
  • Fax: 815-986-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number036054365
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateIL

VIII. Authorized Official

Name: RAMESH B VEMURI
Title or Position: OWNER
Credential: M.D.
Phone: 815-444-9999