1295835023 NPI number — AUNT MARTHA'S YOUTH SERVICE CENTER

Table of content: (NPI 1295835023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295835023 NPI number — AUNT MARTHA'S YOUTH SERVICE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUNT MARTHA'S YOUTH SERVICE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AUNT MARTHA'S SEADAC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295835023
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19990 GOVERNORS HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLYMPIA FIELDS
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60461-1021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-747-7100
Provider Business Mailing Address Fax Number:
708-747-0710

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8640 S SOUTH CHICAGO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60617-2314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-731-9100
Provider Business Practice Location Address Fax Number:
708-747-7907
Provider Enumeration Date:
09/22/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
708-825-5976

Provider Taxonomy Codes

  • Taxonomy code: 261QR0405X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 237248446004 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2371881580080 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".