Healthcare Provider Details

I. General information

NPI: 1619104098
Provider Name (Legal Business Name): AUNT MARTHAS YOUTH SERVICE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 03/22/2011
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

19990 GOVERNORS HWY
OLYMPIA FIELDS IL
60461-1021
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-7100
  • Fax:
Mailing address:
  • Phone: 708-747-7100
  • 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: MR. CHRISTOPHER J NORDLOH
Title or Position: CFO
Credential:
Phone: 708-747-7100