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General NPI Number Information
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NPI Number | 1043746720
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Entity Type | Organization
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Legal Business Name | AUNT MARTHA'S HEALTH AND WELLNESS
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Dates
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Enumeration Date | 05/02/2017
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Last Update Date | 09/29/2023
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Provider Practice Location Address
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Address Line | 345 EXECUTIVE PKWY STE L1
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City | ROCKFORD
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State | IL
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Zip | 61107-5291
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Country | US
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Telephone | 877-692-8686
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Fax |
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Provider Business Mailing Address
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Address Line | 19990 GOVERNORS HWY
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City | OLYMPIA FIELDS
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State | IL
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Zip | 60461-1021
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Country | US
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Telephone | 708-747-7100
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Fax |
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Authorized Official
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Title or Position | COO
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Name | AUDREY PENNINGTON
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Credential |
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Telephone | 773-802-7645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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