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General NPI Number Information
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NPI Number | 1902269095
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Entity Type | Organization
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Legal Business Name | AUNT MATHA'S YOUTH SERVICE CENTER
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Dates
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Enumeration Date | 04/05/2016
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Last Update Date | 04/05/2016
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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 | 898 BROMPTON CIR
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City | BOLINGBROOK
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State | IL
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Zip | 60440-1485
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Country | US
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Telephone | 847-420-9664
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Fax |
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Authorized Official
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Title or Position | PCP - FAMILY PRACTICE MEDICINE
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Name | DR. CLARENCE PARKS
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Credential | MD
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Telephone | 815-275-1540
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 1275992323
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License Number State | IL
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