Healthcare Provider Details

I. General information

NPI: 1912489188
Provider Name (Legal Business Name): AUNT MARTHA'S HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461
US

IV. Provider business mailing address

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461-1021
US

V. Phone/Fax

Practice location:
  • Phone: 877-692-8686
  • Fax:
Mailing address:
  • Phone: 877-692-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. MARY MARTIN
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CPA
Phone: 708-825-5976