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General NPI Number Information
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NPI Number | 1316307259
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Entity Type | Organization
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Legal Business Name | THE MATHERS CLINIC LLC
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Dates
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Enumeration Date | 03/04/2016
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Last Update Date | 01/26/2017
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Provider Practice Location Address
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Address Line | 715 W JUDD ST
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City | WOODSTOCK
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State | IL
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Zip | 60098-3186
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Country | US
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Telephone | 815-444-9999
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Fax |
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Provider Business Mailing Address
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Address Line | 145 S VIRGINIA ST SUITE C
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City | CRYSTAL LAKE
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State | IL
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Zip | 60014
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RAMESH VEMURI
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Credential |
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Telephone | 815-444-9999
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 036054365
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License Number State | IL
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