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NPI Code Detail

MEDICARE: AUNT MARTHAS YOUTH SERVICE CENTER INC

MEDICARE: AUNT MARTHAS 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
1261QF0400XFederally Qualified Health Center (FQHC)035IL

General Provider Information

NPI Number : 1922148501
Entity Type Code : Organization
Provider Name (Legal Business Name) : AUNT MARTHAS 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 : 1536 VINCENNES AVE
Second Line :
City : CHICAGO HEIGHTS
State : IL
Zip : 60411-3458
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 : 02/06/2007
Last Update Date : 07/21/2022

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