Healthcare Provider Details

I. General information

NPI: 1013555416
Provider Name (Legal Business Name): MATHERS RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 TOWNE CENTRE LN
FOX LAKE IL
60020-1801
US

IV. Provider business mailing address

101 TOWNE CENTRE LN
FOX LAKE IL
60020-1801
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 TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SRIHARI VEMURI
Title or Position: CFO
Credential:
Phone: 815-444-9999