Healthcare Provider Details

I. General information

NPI: 1902269095
Provider Name (Legal Business Name): AUNT MATHA'S YOUTH SERVICE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 04/05/2016
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

898 BROMPTON CIR
BOLINGBROOK IL
60440-1485
US

V. Phone/Fax

Practice location:
  • Phone: 708-747-7100
  • Fax:
Mailing address:
  • Phone: 847-420-9664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number1275992323
License Number StateIL

VIII. Authorized Official

Name: DR. CLARENCE PARKS
Title or Position: PCP - FAMILY PRACTICE MEDICINE
Credential: MD
Phone: 815-275-1540