Healthcare Provider Details

I. General information

NPI: 1033410477
Provider Name (Legal Business Name): ELEMENTAL CENTER LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2010
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14484 JOHN HUMPHREY DR
ORLAND PARK IL
60462-2638
US

IV. Provider business mailing address

14484 JOHN HUMPHREY DR
ORLAND PARK IL
60462-2638
US

V. Phone/Fax

Practice location:
  • Phone: 708-364-0580
  • Fax: 708-364-0480
Mailing address:
  • Phone: 708-364-0580
  • Fax: 708-364-0480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036103889
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036103889
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MARTINS A ADEOYE
Title or Position: CEO
Credential: MD
Phone: 708-364-0580