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General NPI Number Information
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NPI Number | 1225080922
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Entity Type | Organization
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Legal Business Name | AUNT MARTHAS YOUTH SERVICE CENTER
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Dates
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Enumeration Date | 05/17/2006
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Last Update Date | 12/02/2010
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Provider Practice Location 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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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 | CFO
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Name | MR. CHRISTOPHER J NORDLOH
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Credential |
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Telephone | 708-747-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 251J00000X
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Taxonomy Name | Nursing Care Agency
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License Number |
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License Number State | IL
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Taxonomy #5
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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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