Healthcare Provider Details

I. General information

NPI: 1609124676
Provider Name (Legal Business Name): AUNT MARTHAS YOUTH SERVICE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2012
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461-1021
US

IV. Provider business mailing address

1301 COPPERFIELD AVE SUITE 202
JOLIET IL
60432-2054
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER J NORDLOH
Title or Position: CFO
Credential:
Phone: 708-747-7100