MEDICARE: AUNT MARTHA'S YOUTH SERVICE CENTER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1780828962
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUNT MARTHA'S YOUTH SERVICE CENTER, INC

Provider Business Mailing Address
First Line	:	19990 GOVERNORS HWY
Second Line	:
City	:	OLYMPIA FIELDS
State	:	IL
Zip	:	60461-1021
Country	:	US
Telephone Number	:	708-747-7100
Fax Number	:

Provider Business Practice Location Address
First Line	:	23485 WESTERN AVE
Second Line	:
City	:	PARK FOREST
State	:	IL
Zip	:	60466-2609
Country	:	US
Telephone Number	:	708-747-7100
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. CHRISTOPHER J NORDLOH
Credential	:
Telephone Number	:	708-747-7100

Provider Enumeration Date	:	05/01/2009
Last Update Date	:	12/02/2010

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