Healthcare Provider Details

I. General information

NPI: 1205570942
Provider Name (Legal Business Name): YOUNG 60 PLUS CLUB LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 12/29/2023
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4437 LINCOLN HWY
MATTESON IL
60443-2317
US

IV. Provider business mailing address

4437 LINCOLN HWY
MATTESON IL
60443-2317
US

V. Phone/Fax

Practice location:
  • Phone: 833-960-7587
  • Fax: 309-882-0065
Mailing address:
  • Phone: 833-960-7587
  • Fax: 309-882-0065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name: BRITTNEY M JETER
Title or Position: CEO
Credential: LPN, IPN, MA,
Phone: 833-960-7587